Transnasal Endoscopic Surgery Research Articles

Endoscopic transnasal surgery for skull base chondrosarcomas

Endoscopic transnasal surgery for skull base chondrosarcomas

Endoscopic Transnasal Resection of Trigeminal Schwannoma.

Trigeminal schwannoma is a rare skull base tumor that can be managed in a variety of treatments including image observation, surgery, stereotactic radiosurgery, such as gamma knife radiosurgery (GKS), and combination of these. Endoscopic transnasal resection is very effective when the tumor is not invading far laterally, or the risk of cerebrospinal fluid (CSF) leak is estimated to be low. A 74-year-old man with a history of prostate cancer and diabetes presented with left oculomotor nerve palsy over a month. Magnetic resonance images (MRI) demonstrated a 25-mm mass in the left cavernous sinus protruding to the left orbit via the superior orbital fissure ( Fig. 1 ). The patient underwent endoscopic transnasal surgery to decompress the mass. The surgery was uneventful, and postoperative MRI demonstrated satisfactory subtotal resection of the mass ( Fig. 2 ). The final pathology returned as schwannoma. At 1-year follow-up, the tumor slowly enlarged, and the patient underwent GKS with a marginal dose of 14 Gy. At the last follow-up, 4 months after GKS, the tumor was stable. Unfortunately the patient deceased from the known prostate cancer. Endoscopic transnasal surgery was especially useful in this case, considering the preoperative known cancer state that management of this benign tumor did not ruin the quality of life of this patient while minimizing hospitalization, as achieving satisfactory tumor control with aid from postoperative GKS, minimizing complications. The link to the video can be found at: https://youtu.be/Q0Ugc2VFV4w .

EVALUATION OF TRANS-NASAL ENDOSCOPIC CROSS-OVER FLAP TECHNIQUE IN THE REPAIR OF CHOANAL ATRESIA

Background: Choanal atresia (CA) is a widely recognized craniofacial disorder characterized by the obliteration of the posterior nasal opening, due to the imperforation of the oronasal membrane and overgrowth of the horizontal and vertical process of the palatine bone during weeks 4-11 of the gestation process. Objective: To evaluate the efficacy of trans-nasal endoscopic cross-over flap technique in the repair of choanal atresia with long-term follow-up. Patients and methods: This study was conducted on 20 choanal atresia cases that were managed by the endoscopic transnasal approach using cross-over flap technique at the Department of Otorhinolaryngology, Bab EL-Sharia and AL-Hussein Hospitals, Faculty of Medicine, AL-Azhar University from December 2018 to January 2020. Results: The study included 20 cases: 13 females and 7 males, 5 cases were bilateral, 15 cases were unilateral. Four cases were bony atretic plate, and 16 cases were mixed atretic plate. Four cases (20%) needed post-operative revision repair due to restenosis of the choana. Revision was more common in bilateral cases than unilateral cases and in bony type than mixed type. Also, revision was common in patients with associated malformations, and in patients done before 10 days. Conclusion: Transnasal endoscopic surgery using cross-over flap technique is one of the best choices in the management of the choanal atresia. Endoscopy and CT are the methods of choice for diagnosis.

Real-to-virtual domain transfer-based depth estimation for real-time 3D annotation in transnasal surgery: a study of annotation accuracy and stability

PurposeSurgical annotation promotes effective communication between medical personnel during surgical procedures. However, existing approaches to 2D annotations are mostly static with respect to a display. In this work, we propose a method to achieve 3D annotations that anchor rigidly and stably to target structures upon camera movement in a transnasal endoscopic surgery setting.MethodsThis is accomplished through intra-operative endoscope tracking and monocular depth estimation. A virtual endoscopic environment is utilized to train a supervised depth estimation network. An adversarial network transfers the style from the real endoscopic view to a synthetic-like view for input into the depth estimation network, wherein framewise depth can be obtained in real time.Results(1) Accuracy: Framewise depth was predicted from images captured from within a nasal airway phantom and compared with ground truth, achieving a SSIM value of 0.8310 ± 0.0655. (2) Stability: mean absolute error (MAE) between reference and predicted depth of a target point was 1.1330 ± 0.9957 mm.ConclusionBoth the accuracy and stability evaluations demonstrated the feasibility and practicality of our proposed method for achieving 3D annotations.

Radical versus Functional Endoscopic Sinus Surgery for Osteitis in Chronic Rhinosinusitis

Introduction: Osteitis in chronic rhinosinusitis (CRS) is a predictive factor of disease severity and an important potential reason for disease recalcitrance. Other than medical treatment, transnasal endoscopic surgery could be another choice to deal with osteitis in CRS. Objective: In this study, 2 different surgical outcomes and influence in patients with osteitis in CRS were discussed. Methods: A retrospective analysis of 51 cases was carried out. Osteitis in CRS was confirmed by sinus computed tomography (CT). According to surgical management, patients were divided into the radical endoscopic sinus surgery (RESS) group (n = 24) and functional endoscopic sinus surgery (FESS) group (n = 27). Baseline measures and postoperative outcomes were evaluated by symptom visual analog scale (VAS), peripheral blood eosinophil percentage, serum total IgE, skin prick test, endoscopy Lund-Kennedy score, CT scan Lund-Mackay score, and global osteitis scoring scale (GOSS) in 2 groups. Results and Conclusions: There was no significant difference between the 2 groups in age, gender, and complicated with allergic rhinitis and asthma. The preoperative symptom VAS score and endoscopy Lund-Kennedy score were higher in the RESS group than in the FESS group, and the Lund-Mackay score and GOSS score were similar in the 2 groups. One year after surgery, symptom VAS scores, endoscopy Lund-Kennedy score, and Lund-Mackay score were significantly lower in the 2 groups. The endoscopy Lund-Kennedy score and Lund-Mackay score were lower in the RESS group than in the FESS group 1 year after surgery. RESS was more effective in reducing inflammatory load of sinuses in patients with osteitis in CRS.

Anatomical localization of horizontal segment of the petrous internal carotid artery in transnasal endoscopic skull base surgery

Objective To discuss the localization of horizontal segment of petrous internal carotid artery in transnasal endoscopic skull base surgery, and to provide anatomical data for clinical surgery. Methods The horizontal segment of the petrous internal carotid artery of 5 adult cadaveric heads were exposed by endoscopic transnasal and microscopic open approaches respectively, and the relevant data and images were measured and collected. Results The medial wall of the foramen spinosum is the lateral wall of the isthmus of the eustachian tube, and the thickness of the bone is 0.5 ± 0.2 mm. The medial wall of the isthmus of the eustachian tube is the lateral wall of the posterior genu of the carotid canal and the thickness of the bone is 0.2 ± 0.1 mm. The vidian nerve originates from the anterior genu of the petrous internal carotid artery. The distance from the base of vidian nerve to the isthmus of eustachian tube is 19.2 ± 2.8 mm. Conclusion The foramen spinosum is the landmark of isthmus of the Eustachian tube. The isthmus of the Eustachian tube is the landmark of the posterior genu of the internal carotid artery. The line between the base of the vidian nerve and the isthmus of the Eustachian tube ioks the landmark of horizontal segment of the petrous internal carotid artery.

Retrospective Case Analysis of Transnasal Endoscopic Resection of Benign Orbital Apex Tumors: Some Thoughts on Transnasal Endoscopic Surgery.

Purpose To deeply discuss the patient selection, surgical planning, surgical techniques, and the therapeutic challenge for endoscopic transnasal resection of benign orbital apex tumors (OATs). Methods We retrospectively analyzed the cases of 18 patients (18 eyes) with orbital apex cavernous hemangioma (OACH) who underwent endoscopic transnasal approach for resection of the tumor in Zhongshan Ophthalmic Center from March 2016 to May 2020. At each follow-up visit, the patients underwent measurement of their best-corrected visual acuity (BCVA), slit-lamp examination, indirect ophthalmoscopy, and visual field testing. Results There were 18 patients, 7 males and 11 females, with a mean age of 49.9 ± 12.6 years (range: 26 to 70 years). All 18 patients had unilateral tumors. Among the 18 cases, 13 were located in the right orbit and 5 were located in the left orbit. Sixteen patients underwent purely endoscopic transnasal surgery, and the other 2 patients underwent an endoscopic transnasal approach combined with a transcutaneous or transconjunctival surgical approach. Fourteen patients' OACHs were removed completely, 1 patient's OACH was partly removed, and 3 patients underwent pure decompression of the optic nerve. Fourteen patients gained improved or stable BCVA after surgery. Three patients showed postoperative vision decline, and 1 patient had no light perception after surgery. Conclusions Endoscopic surgery is an effective surgical technique for the treatment of benign tumors in the orbital apex. It is necessary to strictly select patients and fully evaluate the benefits and risks of tumor completely or partly removed.

Trigger electromyography in endoscopic transnasal surgery of skull base tumors

Introduction . The development of minimally invasive technologies in recent decades has expanded the indications for the use of endoscopic transnasal transsphenoidal approaches in surgery of skull base tumors. It became possible to perform surgical interventions aimed at removing tumors of the base of the skull that spread to the area of the passage of cranial nerves (cavernous sinus, clival area, cerebello-pontine angle), which is associated with the risk of damage to certain cranial nerves. The study objective is to evaluate the effectiveness of trigger electromyography in providing anatomical and functional preservation of cranial nerves during endoscopic endonasal transsphenoidal removal of skull base tumors. Materials and methods . The study is based on statistical analysis and comparison of the results of surgical treatment of two groups of patients with various tumors of the base of the skull: the main group (30 patients with using trigger electromyography to identify cranial nerves intraoperatively) and the control group (43 patients without using this method). The effectiveness and safety of using the method of intraoperative identification of cranial nerves was evaluated based on a comparison of basic characteristics, treatment outcomes, and factors potentially affecting them. Results . Fifty-seven (57) cranial nerves were identified intraoperatively in the main group. The frequency of radical removal was 1.6 times higher in the main group (70 % vs 44.2 %, p = 0.03). When analyzing the dynamics of the state of motor cranial nerves after surgery in the main and control groups, it was shown that negative dynamics prevailed in the control group — 37.2 % vs 13.3 % (p = 0.03), and positive dynamics prevailed in the main group (37.3 % vs 13.9 %), 2.8 times (p = 0.08). Conclusion . The obtained data indicate that the use of the intraoperative identification method in endoscopic transnasal surgery of skull base tumors can positively affect the radical removal of tumors and the preservation of cranial nerve function in the postoperative period.

Transnasal endoscopic skull base and brain surgery: Surgical anatomy and its applications. Aldo C.StammJoaoMangussi‐GomesNew York, NY: Thieme, 2019, 690 pp., $229.99.

Transnasal endoscopic skull base and brain surgery: Surgical anatomy and its applications. Aldo C.StammJoaoMangussi‐GomesNew York, NY: Thieme, 2019, 690 pp., $229.99.

Transnasal Endoscopic Surgery for Suprasellar Meningiomas.

Endoscopic trans-nasal surgery has evolved a long way from the days of narrow corridors with high rates of cerebrospinal fluid (CSF) leak to the present state of HD optics with better tissue differentiation, extended approaches, and use of vascularized flaps for defect closure. Trans-nasal approach is an established technique for pituitary tumors practiced worldwide. However, trans-nasal endoscopic excision of suprasellar meningiomas provides a tougher challenge in terms of instrument manipulation, tumor excision with good visual outcome, and a robust defect closure to prevent CSF leaks. Out of 83 cases of midline anterior cranial fossa meningiomas operated over 14 years, our experience in 12 cases of suprasellar meningiomas for radical resection via the trans-nasal endoscopic route is discussed. Amongst these, six were excised via primary extended endoscopic trans-sphenoidal surgery, four cases had a residual lesion or recurrence after primary transcranial surgery, and two cases involved a combined transcranial and extended endoscopic approach. Visual improvement along with resolution of headache was seen in all patients postoperatively. None of the patients had CSF leak requiring further repair. Syndrome of inappropriate antidiuretic hormone was found in one patient, which was transient and easily corrected. Trans-nasal endoscopic surgery for suprasellar meningiomas is an effective technique that provides results of tumor excision comparable to the transcranial approach in suitable cases. Visual outcome was found to be superior, and rates of CSF leak were remarkably reduced with vascularized flap. However, each case must be assessed individually and lateral extension beyond the optic canals with internal carotid artery encasement must be considered before planning surgery.

Recovery peculiarities and complications in the nasal cavity caused by skull base reconstruction with nasoseptal flap after transnasal removal of chiasmo-sellar mass lesions

Today, endoscopic endonasal approach is considered the gold standard in skull base surgery of the chiasmosellar region. Advances in transnasal endoscopic skull base surgery allow conducting more extensive interventions via wider approaches which requires more complicated plastic closure of the skull base defect. In 2006, G. Haddad et al. suggested using a vascularized nasoseptal flap to reconstruct a skull base defect. This method is generally accepted at present due to its reliability and low frequency of postoperative complications. The purpose of this article is to analyze publications on possible complications and pathological conditions of the nasal cavity when using a vascularized nasoseptal flap for skull base surgery after removal of neoplasms of the chiasmo-sellar region. The study included articles found in the Pubmed database (2006–2020) which described frequency and character of complications caused by skull base defect reconstruction by a nasoseptal flap after transnasal removal of chiasmo-sellar neoplasms. According to the literature review, the following complications are reported: cerebrospinal fluid leak, flap necrosis and infectious complications, pathological changes in the nasal cavity: prolonged crusting, synechiae, epistaxis, septum perforation, sinusitis, subatrophic changes of mucosae, nasolacrimal duct obstruction, olfactory dysfunction. The authors conclude that the nasoseptal flap is, undoubtedly, an effective material for reconstruction of dural defects by endoscopic endonasal skull base surgery, because of its good viability due to the preserved blood supply and high tightness of the plasty. However, there is a risk of complications in the nasal cavity. For these reasons, development of effective methods for prevention of nasal complications after using a vascularized flap in endoscopic endonasal surgery is an important issue today.

The clinical features, recurrence risks and surgical strategies of bone invasive pituitary adenomas

ObjectiveBone invasive pituitary adenomas (BIPAs) show obvious malignant behaviour. The aim of this study was to analyse the clinical features, prognosis, recurrence risks and surgical strategies of BIPAs. Patients and methodsClinical charts and radiological information were reviewed retrospectively in 107 consecutive cases of BIPAs. Transnasal endoscopic surgery was adopted with the goal of removing tumours. Scheduled follow-up was performed. ResultsClinical variable analyses revealed a significant correlation between bone invasive range and sex, tumour volume and tumour regrowth. Gross total resection, subtotal resection and partial resection were achieved in 26 cases (24.3 %), 28 cases (26.2 %) and 53 cases (49.5 %), respectively. There was a significant correlation between nongross total resection and female sex, young age, large tumour volume, bone invasive range, tumour regrowth and functional pituitary adenomas in BIPAs. The tumour regrowth rates at 3 years, 5 years and 10 years were 45.3 %, 76.3 % and 97.5 %, respectively. Kaplan-Meier curve analysis showed that tumour volume, bone invasion range, age, recurrent tumours and tumour resection degree were associated with BIPA regrowth. Multivariate analysis showed that tumour resection degree, bone invasive range, and tumour diameter were independent risk factors for BIPA regrowth. ConclusionBIPAs have the characteristics of high surgical risk, low GTR rate and high recurrence rate. There was a significant correlation between bone invasive range and sex, tumour volume and tumour regrowth in BIPAs. Bone invasive range is an independent risk factor for BIPA regrowth.

Lista de chequeo preoperatorio para la cirugía endoscópica de hipófisis

Introducción: Las listas de chequeo son herramientas que buscan evitar errores y complicaciones. El adenoma hipofisiario es la primera causa de cirugía endoscópica transnasal de la región selar y se estima un 20% de complicaciones derivadas de esta cirugía.
 
 Objetivo: Desarrollar una lista de chequeo preoperatoria que sirva como una guía para la evaluación prequirúrgica de los pacientes a quienes se les vaya a realizar cirugías de la región selar.
 
 Metodología: Se realizó una revisión de la literatura para desarrollar una lista de chequeo preliminar y una serie de declaraciones que resumían los puntos importantes de la lista. Se construyó un comité de expertos en cirugía endoscópica de la base de cráneo conformado por neurocirujanos y otorrinolaringólogos de hospitales de Bogotá. Utilizando la metodología Delphi modificada se llegó a un consenso para la realización de la lista de chequeo final.
 
 Resultados:
 Se describieron 15 declaraciones y de estas se vio una discrepancia en seis declaraciones. Se realizaron modificaciones en cinco declaraciones, llegando así a un consenso entre los expertos participantes. La lista de chequeo final aprobada está compuesta por 4 ítems.
 Discusión/conclusiones: 
 La cirugía para el manejo de la patología de la región selar es compleja y requiere de un equipo quirúrgico entrenado y disciplinado para lograr los mejores desenlaces posibles. Consideramos que nuestra lista de chequeo es una herramienta que permitirá a los equipos que realizan estas cirugías en Colombia tener una visión más completa del paciente y eventualmente ayudar a evitar errores y posibles complicaciones.

Management of anterior fossa cephaloceles.

Skull base cephaloceles (SBCs) are defined as herniation of intracranial content through the skull base and are classified based on composition, etiology, and topographic location. Anterior SBCs frequently protrude in the sinonasal cavity, and consequently are at potential risk of infection. Therefore, the current recommendation is to treat SBCs with the primary intent of preventing meningitis, and surgery represents the mainstay of treatment. Anterior SBCs may display a wide spectrum of severity and complexity, and in each case the risks and benefits of surgical approaches are to be carefully weighted based on thorough assessment of symptoms, age, general conditions, location and size of the lesion, as well as expertise of the surgeon. In the last 30 years, the evolution and diffusion of transnasal endoscopic surgery have substantially changed the surgical management of the majority of SBC. In the past, they were treated exclusively with open transcranial approaches that may be burdened by relevant morbidity and risk for severe complications. The transnasal endoscopic corridor now provides easy access to the lesion and different reconstructive strategies using endonasal pedicled flaps, without any external incision, cranioplasty or brain manipulation. However, there are still scenarios in which an exclusive transnasal endoscopic route is contraindicated. The aim of the present review was to provide an overview on the comprehensive management of anterior SBC, with a particular focus on lesions suitable for endoscopic surgery. Furthermore, special aspects of SBC management in children and adults will be highlighted.

Endoscopic Management of a Large Tornwaldt Cyst: A Case Report

ABSTRACT
 Objective: To report successful marsupialization of a large Tornwaldt cyst using combined transnasal and transoral endoscopic surgery in a 7-year-old girl who presented with nasal obstruction.
 Methods:Design: Case ReportSetting: Tertiary Government Training HospitalPatient: One
 Result: A 7-year-old girl presented with an 11-month history of recurrent yellowish nasal discharge gradually associated with nasal obstruction. Examination revealed a large, well encapsulated, broad-based cystic mass in the nasopharynx immediately adjacent to the posterior choanae, continuing posterior to the soft palate (pushing the uvula anteriorly) and extending inferiorly to the epiglottic area. Computerized Tomography (CT) demonstrated a well-circumscribed, midline hypodense mass with fluid attenuation obstructing the nasopharyngeal area extending inferiorly to the oropharyngeal area. Endoscopic marsupialization via transnasal and transoral approach was successful, and a respiratory epithelium-lined cyst consistent with a Tornwaldt cyst was confirmed by histopathologic examination
 Conclusion: Combined transnasal and transoral endoscopic marsupialization is possible a for a large symptomatic Tornwaldt cyst in a pediatric patient with relatively smaller and complex nasal cavities.

A novel aerosolisation mitigation device for endoscopic sinus and skull base surgery in the COVID-19 era.

PurposeTo provide a novel solution to reduce aerosol exposure in the operating room during endoscopic sinus and skull base procedures in the COVID-19 era.MethodsWe have designed a 3D printable midfacial mask that partially seals the nose, while allowing instrumentation during endoscopic transnasal surgery. The mask when connected to a vacuum system creates a constant negative pressure inside it, sucking out aerosols and gases generated during surgical procedures. Its effectiveness was tested using vapour exhalations by a human volunteer and drilling bone in a head model. The physical barrier effect was measured using fluorescein atomization in a head model.ResultsThe pressure and airflow measured remained negative inside it in all the different situations tested. The mask was capable of completely evacuating human adult exhalation, and was more effective than the hand suction instrument. However, it was as effective as hand suction instrument at preventing aerosol spread from bone drilling. The physical barrier effect achieved a 72% reduction in the splatter created from the fluorescein atomization.ConclusionsThe mask effectively prevented the spread of aerosols and reduced droplet spread during simulated transnasal endoscopic skull base surgery in laboratory conditions. This device has potential benefits in protecting surgical personnel against airborne transmission of COVID-19 and could be useful in reducing chronic exposure to the hazard of surgical smoke.Electronic supplementary materialThe online version of this article (10.1007/s00405-020-06462-1) contains supplementary material, which is available to authorized users.

Quality of Life Evaluation After Trans-Nasal Endoscopic Surgery for Skull Base Tumors.

The excellent surgical results obtained with transnasal endoscopic approach to the anterior skull base (ASB) are universally recognized; less is known about the quality of life of patients after surgery. The aim of this study is to analyze the quality of life of patients after endoscopic transnasal surgery for the treatment of neoplasms of the ASB. We conducted a retrospective review of patients who underwent transnasal endoscopic surgery for treatment of ASB tumors at the Tertiary Referral Center University Hospital of Verona. All patients were asked to complete the Anterior Skull Base Questionnaire (ASBQ), the Skull Base Inventory (SBI), and the Sino-nasal Outcome Test - 22 Items (SNOT-22) after surgical treatment. The study population was divided into subgroups; a statistical analysis of the overall results and of the different questionnaire domains was performed. 51 patients were enrolled in this study. The average score was 3.04 for ASBQ, 4.05 for SBI and 28.88 for SNOT-22. Analysis of the overall results for the ASBQ showed a lower quality of life in patients after recurrent surgery and in female patients. The SBI showed similar results in relation to recurrent surgery and radiotherapy. Similarly, the results for SNOT-22 highlighted the negative impact of recurrent surgery and radiotherapy. Our results confirmed that the endoscopic transnasal approach shows excellent results not only in terms of surgical outcome, but also for the possibility of ensuring a good QoL after treatment. Recurrent surgery and radiation treatments were the most important negative prognostic factors.

Surgical Field Quality in Trans-Nasal Endoscopic Surgeries Using Lignocaine Infusion and Dexmedetomidine Infusion. A Prospective Randomized Control Study.

Trans-nasal endoscopic surgery (TNES) is a helpful diagnostic and therapeutic modality in otorhinolaryngology surgeries and requires controlled hypotension for better visualization of the surgical field. Recent literature shows evidence of intravenous Lignocaine infusion to produce the controlled hypotension. The study aims to assess and compare the effects of Lignocaine (LIG) and Dexmedetomidine (DEX) infusion with respect to surgical field quality. 101 Consenting adult patients undergoing elective TNES were double-blinded, randomly allocated in one of the two groups and received either DEX infusion of 0.5ug/kg/hr (n = 51) or LIG infusion of 1.5mg/kg/h (n = 50) after a loading dose. Surgical field score (SVF) as the primary outcome and secondary outcomes such as variations in hemodynamic parameters, the requirement for rescue agents and total blood loss were recorded. Both the groups were comparable with respect to patient demographics, total duration of anesthesia and surgery. SVF scores were significantly better in the LIG group during the first 105min of the surgery (p < 0.05). In response to intubation, hemodynamic parameters were lower in LIG group. The requirement of other adjuvant drugs, total blood loss (166.40ml vs. 251.17ml) and extubation time were also significantly lower in the LIG group. The study concludes that intravenous Lignocaine gives a better surgical field in the first 105min of surgery, comparable hemodynamics and decreased blood loss in patients undergoing TNES as compared to Dexmedetomidine infusion. Hence its role as an agent for controlled hypotension during TNES surgery is promising.

Factors impacting postoperative haemorrhage after transnasal endoscopic surgery

Factors impacting postoperative haemorrhage after transnasal endoscopic surgery

Surgical and clinical outcome in elderly patients affected by non-functional pituitary adenoma treated by endoscopic transnasal transsphenoidal surgery: A monocentric study

Surgical and clinical outcome in elderly patients affected by non-functional pituitary adenoma treated by endoscopic transnasal transsphenoidal surgery: A monocentric study