Extended Endoscopic Endonasal Approach Research Articles

A modern approach to olfactory groove meningiomas.

Management of olfactory groove meningiomas (OGMs) has changed significantly with the advances in extended endoscopic endonasal approaches (EEAs), which is an excellent approach for patients with anosmia since it allows early devascularization and minimizes retraction on the frontal lobes. Craniotomy is best suited for preservation of olfaction. However, not infrequently, a tumor presents after extending outside the reach of an EEA and a solely transcranial approach would require manipulation and retraction of the frontal lobes. These OGMs may best be treated by a staged EEA-craniotomy approach. In this study the authors' goal was to present their case series of patients with OGMs treated with their surgical approach algorithm. The authors conducted an IRB-approved, nonrandomized historic cohort including all consecutive cases of OGMs treated surgically between 2010 and 2020. Patient demographic information, presenting symptoms, operative details, and complications data were collected. Preoperative and postoperative tumor and T2/FLAIR intensity volumes were calculated using Visage Imaging software. Thirty-one patients with OGMs were treated (14 craniotomy only, 11 EEA only, and 6 staged). There was a significant difference in the distribution of patients presenting with anosmia and visual disturbance by approach. Tumor size was significantly correlated with preoperative vasogenic edema. Gross-total resection was achieved in 90% of cases, with near-total resection occurring twice with EEA and once with a staged approach. T2/FLAIR hyperintensity completely resolved in 90% of cases and rates did not differ by approach. Complication rates were not significantly different by approach and included 4 CSF leaks (p = 0.68). A staged approach for the management of large OGMs with associated anosmia and significant lateral extension is a safe and effective option for surgical management. Through utilization of the described algorithm, the authors achieved a high rate of GTR, and this strategy may be considered for large OGMs.

Customized ventral bony and dural opening in the transplanum/transtuberculum and transclival variants of extended endoscopic endonasal approach to suprasellar craniopharyngiomas: an approach-based stepwise cadaveric dissection and clinical applicability.

Optimal initial exposure through an extended endoscopic endonasal approach (EEA) for suprasellar craniopharyngiomas ensures safe and unrestricted surgical access while avoiding overexposure, which may prolong the procedure and increase neurovascular adverse events. Here, the authors outline the surgical nuances of a customized bony and dural opening through the transplanum/transtuberculum and transclival variants of the extended EEA to suprasellar craniopharyngiomas based on the tumor-pituitary stalk relationship. A stepwise cadaveric dissection and intraoperative photographs relevant to the approaches are also provided. Safe maximal resection of suprasellar craniopharyngiomas through extended EEAs can be feasibly and safely achieved by implementing of tailored ventral exposure.

Risk factors for cerebrospinal fluid leak after extended endoscopic endonasal surgery for adult patients with craniopharyngiomas: a multivariate analysis of 364 cases.

Over the last decade, the extended endoscopic endonasal approach (EEEA) has evolved as a credible surgical alternative for removing craniopharyngiomas. However, postoperative cerebrospinal fluid (CSF) leak remains one of the most pressing concerns. Craniopharyngiomas often invade the third ventricle, resulting in a higher rate of third ventricle opening after surgery and potentially increasing the risk of postoperative CSF leak. Identifying the risk factors associated with CSF leak after EEEA for craniopharyngiomas may have more clinical value. Nevertheless, there is a lack of systematic studies on the topic. Previous studies yielded inconsistent results, probably due to heterogeneous pathologies or small sample sizes. Hence, the authors present the largest known single-institution case series of the use of purely EEEA for craniopharyngiomas to systematically study the risk factors for postoperative CSF leak. The authors retrospectively reviewed 364 cases of adult patients with craniopharyngiomas who were treated at their institution from January 2019 to August 2022, and they analyzed the risk factors for postoperative CSF leak. The overall rate of postoperative CSF leak was 4.7%. In the univariate analysis, larger dural defect size (OR 8.293, 95% CI 3.711-18.534, p < 0.001) and lower preoperative serum albumin level (OR 0.812, 95% CI 0.710-0.928, p = 0.002) were associated with higher rates of postoperative CSF leak. Predominantly cystic tumors (OR 0.325, 95% CI 0.122-0.869, p = 0.025) were linked to decreased risk of postoperative CSF leak. However, postoperative lumbar drainage (OR 2.587, 95% CI 0.580-11.537, p = 0.213) and third ventricle opening (OR 1.718, 95% CI 0.548-5.384, p = 0.353) were not related to postoperative CSF leak. In the multivariate analysis, larger dural defect size (OR 8.545, 95% CI 3.684-19.821, p < 0.001) and lower preoperative serum albumin level (OR 0.787, 95% CI 0.673-0.919, p = 0.002) were identified as independent risk factors for postoperative CSF leak. The authors' repair technique yielded a reliable reconstructive outcome for high-flow CSF leak in EEEA for craniopharyngioma. Lower preoperative serum albumin level and larger dural defect size were identified as independent risk factors for postoperative CSF leak, potentially providing new insights into minimizing the risk of postoperative CSF leak. Third ventricle opening was not associated with postoperative CSF leak. Lumbar drainage may not be necessary for high-flow intraoperative leak, but this finding may require validation with a prospective randomized controlled trial in the future.

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal approach resection of tuberculum sellae meningiomas: a single-institution study.

Traditionally, supratentorial craniotomy has been used to sever tuberculum sellae meningiomas (TSMs), but there has been a remarkably increasing tendency of extended endoscopic endonasal approach (EEEA) used to treat TSMs in the recent decade. Several documents have described the advantages and disadvantages of both approaches, but there is no consensus on whether one is superior to the other. This study aimed to compare surgical outcomes between craniotomy and EEEA for TSMS treated at our institution. From January 2015 to December 2021, a total of 84 cases of TSMs were included in this study. Cases were separated into two groups: the craniotomy group and the EEEA group. Their anamneses and surgical records were reviewed. Demographic data, presenting symptoms, tumor volume, extent of resection, visual outcomes, and follow-up data were tabulated. The Kaplan-Meier curves were constructed for the PFS for both cohorts. Complete data were available for 84 surgeries; 39 cases were treated via craniotomy, and 45 were treated via EEEA. Patient demographic data, pre-operative symptoms, and tumor characteristics were similar between the two cohorts. The extent of resection was similar between the two groups (GTR: 91.11% EEEA vs. 87.18% craniotomy; STR 8.89 vs. 12.82%, p = 0.91). There was no difference in visual outcomes between both groups (92.1 vs. 84.84%, p = 0.46). An increased rate of cranial nerve injury was noted in the craniotomy group (0 vs. 10.25%, p = 0.04). Post-operative CSF leak rate occurred in one patient in the EEEA group. The PFS curves (p = 0.52) and recurrence/progression rates (13.33 vs. 20.51%, p = 0.39) were similar between the two groups. Both EEEA and craniotomy can successfully sever TSMs. The recurrence/progression rate and PFS appear to be similar between the two groups. Although there are no differences in EOR and visual outcomes between the two groups, there was a clear trend in the EEEA group to obtain a better outcome. CSF leakage was common in the EEEA cohort, whereas the rate of cranial nerve injury was found to be higher in the craniotomy cohort. We believe that our data support the conclusion that EEEA surgery is the preferred approach for the removal of TSMs.

Anatomic Considerations Guiding Single Versus Multiportal Endoscopic Approaches for Resection of Juvenile Nasopharyngeal Angiofibroma: Cases Series With Graded Multicorridor Resections.

Juvenile nasopharyngeal angiofibromas (JNAs) are characterized by expansive and destructive growth, often invading the midline/paranasal sinuses, pterygopalatine fossa, and infratemporal fossa and can extend into the orbit, cavernous sinus, or intracranially. To evaluete the major benefits of the extended endoscopic endonasal approach (EEA) for JNA resection as compared with more traditional and invasive transpalatal and transfacial approaches. When JNAs extend into lateral anatomic compartments, the optimal operative trajectory often requires additional approach strategies or surgical staging. We retrospectively reviewed 8 cases of large JNAs arising in symptomatic adolescent boys (University of Pittsburgh Medical Center Stages II, III, and V) and discuss anatomic and tumor considerations guiding the decision of a pure EEA vs combined EEA and sublabial transmaxillary approach (Caldwell-Luc). A pure extended EEA was used in 6 JNA cases (UPMC Stages II-III); a multiportal EEA + Caldwell-Luc maxillotomy was used in 2 cases. One of the 2 patients (UPMC Stage V) previously treated with multiportal EEA + Caldwell-Luc maxillotomy underwent staged left temporal/transzygomatic craniotomy, obtaining gross total resection. Seven patients ultimately underwent complete removal without recurrence. One patient with a small residual JNA (UPMC II) underwent stereotactic radiosurgery without progression to date. JNAs with lateral extension into the infratemporal fossa often benefited from additional lateral exposure using a Caldwell-Luc maxillotomy. Cases with significant skull base and/or dural involvement may undergo staged surgical treatment; temporalis + transzygomatic craniotomy is often useful for second-stage approaches for residual tumor in these lateral infratemporal or intracranial regions. SRS should be considered for residual tumor if additional surgery is not warranted.

Extended endoscopic endonasal approach for resecting anterior intrinsic third ventricular craniopharyngioma.

BackgroundThe surgical treatment of the extended endoscopic endonasal approach (EEEA) is a safe and effective treatment for suprasellar craniopharyngiomas. However, due to damage to the hypothalamus and third ventricle floor (TVF), EEEA is generally regarded as unsuitable in treating intrinsic third ventricle craniopharyngioma (ITVC) that is entirely within the third ventricle. Until now, there have been only a small number of reports using EEEA to treat TVC via a supra-infrachiasmatic approach. Given that the translamina terminalis (TLT) corridor was used in the transcranial subfrontal approach, EEEA via a suprachiasmatic approach may be feasible and practical to treat ITVC. In the current study, we accumulated experience applying the suprachiasmatic translamina terminalis (STLT) corridor for anterior treatment of ITVC.MethodsFrom March 2016 to December 2020, 14 patients with ITVC in our center were analyzed retrospectively. All patients underwent surgery by EEEA via an STLT corridor. The multilayer reconstruction technique was adopted to achieve skull base reconstruction. Data concerning the patient’s tumor resection, vision, hypophyseal hormone, and complications were collected.ResultsGross-total resection was achieved in 13 (92.8%) of14 patients, with achievement of near-total (90%) resection in the remaining 1 patient. Nine cases (64.3%) were papillary craniopharyngiomas, and the other 5 cases were adamantinomatous subtypes. Postoperatively, 3 patients with pituitary insufficiency received hormone replacement therapy. No permanent diabetes insipidus or hypothalamic obesity was found. All pairs showed significant improvement or stability in vision except 1 patient who encountered visual deterioration. No other neurological deficit occurred postoperatively. Observation results for the exudation of nasal tissue and the length of hospitalization were satisfactory. After a mean follow-up period of 26.2 months, tumor recurrence was not observed.ConclusionTLT is a minimally invasive corridor used in EEEA for treating anterior ITVC without increasing risks of visual and hormonal deficits. The multilayered reconstruction technique we used is a safe and effective method for achieving watertight closure and avoiding cerebrospinal fluid leaks and infection. The endonasal approach via STLT provides a new, safe and efficacious operative strategy that should be considered a surgical alternative in treating ITVC.

Overview and Pitfalls of the Extended Trans:Nasal Endoscopic Approach

The extended endoscopic endonasal approach(EEA)has been expanding in recent years with the development of instruments and surgical techniques. Basically, sela, extradural, and intranasal lesions such as pituitary tumor, craniopharyngioma, chordoma, chondrosarcoma, and cholesterol granuloma are indicated. Intradural lesions or lesions that extend laterally or downward to the craniocervical junction are more difficult to operate. In addition, cases of hard tumor with calcification of the tumor, cases in which the tumor involves important blood vessels, re-operative cases, and cases after radiotherapy are also difficult cases and should be considered preoperatively. In recent years, we have been trying to keep the nasal structures as much as possible without removing nasal structure, but in cases where the tumor has invaded and destroyed the nasal structures, extended EEA is necessary. The anatomy of the extended EEA is complicated and not common among neurosurgeons. In this chapter, we present the basic anatomy and surgical cases to be understood in extended EEA and explain the pitfalls.

Prediction of Post-operative Visual Deterioration Using Visual-Evoked Potential Latency in Extended Endoscopic Endonasal Resection of Craniopharyngiomas

Background: The current study aimed to investigate the predictive value of visual-evoked potential (VEP) latency for post-operative visual deterioration in patients undergoing craniopharyngioma resection via extended endoscopic endonasal approach (EEEA).Methods: Data from 90 patients who underwent craniopharyngioma resection via EEEA with intraoperative VEP monitoring were retrospectively reviewed. P100 latency was compared between patients with and without post-operative visual deterioration, and the threshold value of P100 latency for predicting post-operative visual deterioration was calculated by the receiver operating characteristic curve analysis. In addition, other potential prognostic factors regarding post-operative visual outcomes were also analyzed by multivariate analysis.Results: Patients with post-operative visual deterioration showed a significantly longer VEP latency than those without (p < 0.001). An extension over 8.61% in VEP latency was identified as a predictor of post-operative visual deterioration (p < 0.001). By contrast, longer preoperative visual impairment duration and larger tumor volume were not significant predictors for post-operative visual deterioration.Conclusions: The current study revealed that intraoperative VEP monitoring in EEEA is effective for predicting post-operative visual deterioration, and an extension over 8.61% in VEP latency can be used as a critical cut-off value to predict post-operative visual deterioration.

Osaka Sliding Knot Seals Dural Defect Simply in Extended Endoscopic Endonasal Approach

An extended endoscopic endonasal approach (EEA) has become standard for parasellar and midline skull base lesions. However, postoperative leakage of cerebrospinal fluid (CSF) can result from dural defects after lesion removal. We present a simple and effective technique, the Osaka sliding knot, to prevent CSF leakage. Between November 2018 and March 2021, a total of 41 patients underwent reconstruction of skull base defects with intraoperative high-flow CSF leaks after extended EEA by using this closure technique, of whom only 1 patient experienced postoperative CSF leakage. This technically simple and efficient method seals the dural defect to prevent CSF leakage after surgeries using an extended EEA.

The Rostral Mucosa: The Door to Open and Close for Targeted Endoscopic Endonasal Approaches to the Clivus.

Extended endoscopic endonasal approaches (EEAs) have progressively widened the armamentarium of skull base surgeons. In order to reduce approach-related morbidity of EEAs and closure techniques, the development of alternative strategies that minimize the resection of normal tissue and alleviate the use of naso-septal flap (NSF) is needed. We report on a novel targeted approach to the clivus, with incision and closure of the mucosa of the rostrum, as the initial and final step of the approach. To present an alternative minimally invasive approach and reconstruction technique for selected clival chordomas. Three cases of clival chordomas illustrating this technique are provided, together with an operative video. The mucosa of the rostrum is incised and elevated from the underlying bone, as first step of surgery. Following tumor resection with angled scope and instruments, the mucosa of the sphenoid sinus (SS) is removed and the tumor cavity and SS are filled with abdominal fat. The mucosal incision of the rostrum is then sutured. A hangman knot is prepared outside the nasal cavity and tightened after the first stitch and a running suture is performed. We propose, in this preliminary report, a new targeted approach and reconstruction strategy, applying to EEAs the classic concept of skin incision and closure for transcranial approaches. With further development in the instrumentations and visualization tools, this technique may become a valuable minimally invasive endonasal approach for selected lesions.

Reconstruction after extended endonasal approaches to the anterior cranial base: surgical techniques and current results.

The development of extended endoscopic endonasal approaches (EEA) to the anterior skull base has allowed successful resection of selected extradural and intradural skull base tumors through an endonasal corridor, minimizing brain and cranial nerve manipulation. However, as the complexity of the approaches has increased, so has the need for more robust and reliable reconstructive options to minimize morbidity. Reconstructive decision-making after extended EEA for anterior skull base tumors must take into consideration multiple factors including patient characteristics (Body Mass Index, previous surgeries, and radiation), location and the size of the skull base defect. A multilayered reconstruction which includes a combination of free grafts and a vascularized flap is the standard approach to anterior skull base defects after EEA and should be applied in a stepwise manner tailored to each patient. The techniques and materials used to accomplish skull base repair are discussed, the outcomes in the literature are reviewed, and our reconstructive paradigm presented.

Extended endonasal endoscopic approach for anterior midline skull base lesions

AimIn recent years, extended endoscopic endonasal approach (EEEA) has been used as an alternative to transcranial approaches in the treatment of anterior midline skull base lesions. We retrospectively reviewed our cases operated using this technique and compared the results with current literature. MethodThe data of 24 patients who were operated using EEEA in our department between 2010–2018 were retrospectively analyzed. The lesions were located in the midline between the posterior wall of the frontal sinus and tuberculum sella. Tumor locations, histopathological diagnoses, surgical techniques, outcomes and complications were documented. ResultsEleven patients were female and 13 were male. Their ages ranged between 18–75 years (mean 40.5 years). Considering their locations; 12 were in the anterior fossa (50 %), 7 were in the tuberculum sella (29.1 %), and 5 were in both anatomic sites (20.8 %). Histopathologically, our series consisted of 15 meningiomas, 6 osteomas, 2 dermoid tumors and 1 metastatic carcinoma. We achieved gross total resection in 75 % of our patients. Ten patients presented with visual complaints and 7 of them improved postoperatively. Postoperative cerebrospinal fluid leakage (CSF) was observed in 3 patients and one of them developed meningitis and subsequently died of sepsis. ConclusionAlthough the number of cases is low, EEEA seems like a safe, effective and well-tolerated treatment modality for anterior midline skull base lesions. But strict preventive measures should be taken for a possible CSF leak.

Acellular dermal matrix as an alternative to autologous fascia lata for skull base repair following extended endoscopic endonasal approaches.

Skull base reconstruction after extended endoscopic endonasal approaches (EEAs) can be challenging. In addition to the nasoseptal flap, which has been adopted by most centers, autologous fascia lata is also often utilized. Harvesting of fascia lata requires a separate thigh incision, may prolong recovery, and results in a visible scar. In principal, the use of non-autologous materials would be preferable to avoid a second incision and maintain the minimally invasive nature of the approach, assuming the CSF leak rate is not compromised. To assess the efficacy of acellular dermal matrix (ADM) as a non-autologous alternative to autologous fascia lata graft for watertight closure of the cranial base following EEAs. A retrospective chart review of extended EEAs performed before and after the transition from fascia lata to ADM was performed. Cases were frequency matched for approach, pathology, BMI, use of lumbar drainage, and tumor volume. Power analysis was performed to estimate the sample size needed to demonstrate non-inferiority. ADM was used for watertight closure of the cranial base in 19 consecutive extended endoscopic endonasal approaches (16 gasket-seals and 3 buttons) with 1 postoperative CSF leak at the last follow-up (median 5.3, range 1.0-12.6months). All patients had high-flow intraoperative leaks. The cohort included 8 meningiomas, 8 craniopharyngiomas, 2 chordomas, and 1 pituicytoma ranging in size from 0.2 to 37.2cm3 (median 5.5, IQR 2.8-13.3cm3). In 19 historical controls who received fascia lata, there were 2 postoperative CSF leaks. Preliminary results suggest that ADM provides a non-inferior non-autologous alternative to fascia lata for watertight gasket-seal and button closures following extended EEAs, potentially reducing or eliminating the need to harvest autologous tissue.

Techniques and challenges of the expanded endoscopic endonasal access to the ventrolateral skull base during the "far-medial" and "extreme medial" approaches.

Expanding the ventrolateral skull base corridor from the midline of lower clivus to the petroclival fissure is a challenging endonasal surgical task. Resection of lytic lesions like chondrosarcoma can cause cranial nerve morbidities and injury of ICA, necessitating accurate knowledge of correlative endoscopic anatomy with stereotactic landmarks. We describe an extended endoscopic endonasal approach (EEA) for a right petroclival chondrosarcoma with the demonstration of ipsilateral surgical landmarks with contralateral normal correlates, using a stepwise comparative image-guided cadaveric dissection study. EEA for lytic lesions like chondrosarcomas needs to address brain shift and displacement of ICA, posing a chance for cranial nerve morbidities and ICA injury. Meticulous utilization of intraoperative stereotactic landmarks can help avoid and mitigate surgical complications.

Endoscopic surgical resection of tuberculum sellae meningiomas based on decision-making algorithms proposed in the literature

Recent publications and studies propose using decision-making algorithms in choosing the optimal approach for each individual case of tuberculum sellae meningioma (TSM). Minimally invasive endoscopic approaches offer the possibility of early devascularization, reduced brain and nerve retraction and speedy patient recovery. We used the decision-making algorithm proposed in the literature to choose between the extended endoscopic endonasal approach (EEA) or the classic transcranial approaches for resection of tuberculum sella/planum sphenoidale meningiomas, based on anatomical landmarks and lateral extension. We describe rates of gross-total resection, visual outcomes, as well as complications in four cases of TSMs, where EEA was used based on the proposed algorithm. Over a period of 15 months, we used the algorithm in nine patients with tuberculum sella/planum sphenoidale meningiomas, in four of whom we used the extended EEA. The mean follow-up duration was 3 months. Gross-total resection was achieved in three out of the four cases, the fourth being a second operation a long period of time after the classical transcranial approach had been used. Visual improvement was achieved in three out of the four cases. One patient had stable vision. There were no cerebrospinal fluid leaks or any kind of neurological postoperative deterioration, although a patient developed pulmonary embolism, but recovered successfully and was discharged. The algorithm proposed in the literature that was explored here is simple, minimally invasive and can produce excellent outcomes in the surgical resection of TSMs in carefully selected cases.

Clinical application of in situ bone flap in skull base reconstruction in endoscopic endonasal surgery for craniopharyngioma

Objectives To compare different methods of the skull base reconstruction in craniopharyngioma surgery via extended endoscopic endonasal approach (EEEA) and to investigate the advantage and feasibility of in situ bone flap in skull base reconstruction. Methods Twenty-six cases with craniopharyngiomas who underwent complete osseous skull base reconstruction using in situ bone flap in skull base reconstruction and repair in EEEA were enrolled retrospectively into the experimental group at Department of Neurosurgery, Xijing Hospital, Air Force Medical University from July 2016 to December 2017. Thirty-one cases with craniopharyngiomas who underwent partial osseous skull base reconstruction using fashioned piece of nasoseptal bone or artificial bone matrix from March 2015 to June 2016 were enrolled into the control group. The rates of intracranial infection and lumbar cisterna drainage, time from surgery to out-of-bed activity and hospitalization length were compared between the 2 groups. Results Intracranial infection occurred in 2 cases in the control group, whereas no intracranial infection was reported in experimental group. There was no statistically significant difference between the 2 groups (P=0.291). Lumbar cisterna drainage rate in the control group (29.0%, 9/31)was significantly higher than that in the experimental group (3.8%, 1/26, P=0.013). Compared with those in control group, patients in the experimental group were able to get off bed earlier (7.5±1.1 d vs. 12.1±2.4 d, P<0.001). The hospitalization length in the control group was also longer than that in the experimental group (13.5±1.8 d vs. 8.2±0.9 d, P<0.001). There was no delayed cerebrospinal fluid leak or brain hernia during the follow-up period lasting for 3-32 months. Conclusions The multilayer repair using duramax, in situ bone flap and vascularized pedicled nasoseptal flap could significantly reduce the incidence of cerebrospinal fluid rhinorrhea and shorten hospitalization length. Skull base reconstruction using in situ bone flap seems to be an effective procedure for EEEA. The clinical efficacy of using the method in EEEA for craniopharyngioma is valid with bright prospects and deserves clinical promotion. Key words: Craniopharyngioma; Natural orifice endoscopic surgery; Extended endonasal approach; Skull base reconstruction; In situ bone flap

Quality of life after extended versus transsellar endoscopic skull base surgery from 767 patients.

The aim of this study was to compare sinonasal-related quality of life (QOL) in patients treated by extended or transsellar endoscopic skull base surgery. Prospective data analysis. Prospectively collected data from patients who underwent endoscopic skull base surgery between 2012 and 2017 were analyzed. Primary outcomes were preoperative Sino-Nasal Outcome Test-20 (SNOT-20) scores and then 1-month, 3-month, and 6-month follow-up. Comparative analysis was performed between the endoscopic transsellar approach (ETA) group (n = 647) and an extended endoscopic endonasal approach (EEEA) group (n = 120). In ETA group, the SNOT-20 score was compared between patients with a nasoseptal flap (NSF) (ETA-NSF) and without an NSF (ETA-no NSF). The mean total SNOT-20 score was significantly worse in the EEEA than ETA group at 1, 3, and 6 months postoperatively (P < .05). Although there was no significant difference in total SNOT-20 score between the ETA-NSF and ETA-no NSF group at 3 and 6 months after surgery, the percentage of patients with significant change (≥0.8) in the SNOT-20 score was higher in the NSF used group at 1, 3, and 6 months postoperatively (22.92% vs. 13.51%, P = .029; 20.59% vs. 5.59%, P = .039; and 24.00% vs. 4.03%, P = .003, respectively). According to multivariate analysis conducted regarding factors that deteriorate sinonasal QOL at 6 months following surgery, only NSF usage is significantly associated with poor outcome (odds ratio: 4.371, P = .011) CONCLUSIONS: Sinonasal-related QOL was significantly worse in patients treated by the EEEA versus ETA. Use of an NSF is the only poor prognostic factor in sinonasal QOL after endoscopic skull base surgery. 2b Laryngoscope, 129:1318-1324, 2019.

Extended endoscopic endonasal surgery for clival chordoma and chondrosarcoma: Our experience in 14 cases

ObjectiveTo report our experience in the management of chordoma and chondrosarcoma with extended endoscopic endonasal surgery. MethodWe performed a retrospective analysis of a series of 14 patients with clival chordoma or chondrosarcoma who had extended endoscopic endonasal surgery from 2008 to 2016 performed by the same multidisciplinary team. ResultsWe had fourteen patients (male/female 2:1), with a mean age of 49 years for chordoma and 32 for chondrosarcoma. The most common clinical presentation was diplopia in 78.5% of cases, followed by dysphagia in 28.6%. Histologically, 71.4% were chordomas and 28.6% were chondrosarcomas. In addition, invasion of at least two-thirds or more of the clivus was found in 81% of the cases; in 57.1% there was intradural invasion, and in 35.7% invasion of the sella turcica. In 42.8% of cases, the degree of resection was total and in 21.5% subtotal. The most common complication was CSF fistula, occurring in 28.6% of the cases, with only one case requiring surgery to repair it. Adjuvant treatment with Proton Beam was performed in 35.7% of cases and with conventional radiotherapy in 21.5%. Mean follow-up was 53.5 months and tumour recurrence or progression was found in 21.5% of the cases, two of which had not received adjuvant treatment. There were no deaths. ConclusionThe extended endoscopic endonasal approach (EEEA) performed by an experienced team is a good alternative for the management of these lesions. Intradural invasion may be related to an increased risk of complications and worse clinical presentation, in addition to a lower rate of total resection.

Extended endoscopic endonasal approach to the ventral skull base lesions

ObjectiveWith the use of multiple endoscopic endonasal surgical corridors, extended endoscopic endonasal approaches (EEEAs) are now being used to treat a wide range of ventral skull base lesions. Our aim was to present our experience with EEEAs to the ventral skull base lesions. Patients and MethodsThe study group consisted of 106 patients (57 men and 49 women) who underwent surgery for skull base lesions using EEEAs from 2010 to 2017. The EEEA was most commonly used for giant pituitary macroadenomas, sinonasal malignancies, cerebrospinal fluid (CSF) leaks, meningiomas, craniopharyngiomas, and fibro-osseous lesions. Four different approaches were used including transtuberculum-transplanum, transethmoidal-transcribriform, transclival, and transmaxillary-transpterygoidal. ResultsThe overall gross total resection (GTR) rate for these diverse pathologies was 75.0% in 88 patients (excluding the operations performed for non-neoplastic pathologies). GTR was achieved in 100%, 77.8%, 75%, 75%, 72.2%, 62.5%, 60% of fibro-osseous lesions, giant/large pitutary adenomas, meningiomas, esthesioneuroblastomas, sinonasal malignancies, craniopharyngiomas, and chordomas, respectively. The overall rate of improvement in visual fields was 86%. The overall rate of CSF leak was 8.4%. Other surgical complications included intracerebral hematoma and tension pneumocephalus. The mortality rate was 0.9%. ConclusionEEEA is a safe, well-tolerated and effective surgical treatment modality in the management of ventral skull base lesions. It should be performed with close interdisciplinary collaboration. Appropriate case selection is mandatory. However, despite improved reconstruction techniques, postoperative CSF leakage still remains a challenge.

Extended endoscopic endonasal approach for recurrent or residual symptomatic craniopharyngiomas

ObjectivesRemoval of recurrent or residual symptomatic craniopharyngiomas is more challenging than the primary surgery. The extended endoscopic endonasal (EEE) approach has been proposed an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas currently. In this study, we summarized the operative experience and described the feasibility and advantages of this technique in recurrent or residual symptomatic craniopharyngiomas. Patients and methodsA retrospective review of 15 patients (9 males and 6 females) whom underwent EEE approach between April 2012 and February 2017, were included in this study. The lesions included 8 purely suprasellar craniopharyngiomas (2 extraventricular, 6 intraextraventricular), 3 both intra- and suprasellar craniopharyngiomas, and 4 intrasellar craniopharyngiomas. The mean preoperative (that is, EEE approach) tumor volume was 10.54 cm3. The mean follow-up period was 23.1 months (range, 8–54). All patients were analyzed in terms of the treatment effect, complictions and follow-up results. ResultsTotal removal of tumors was achieved in 12 patients (80.0%) and subtotal removal in 3 cases (20.0%). The pituitary stalks were identified in 11 patients during operations and secured in 8 patients. Postoperative visual acuity was improved in 10 cases, and normalization of the impairment was achieved in 3 patients. There were no significant differences between pre and postoperative endocrine function, except in one patient with normal preoperative pituitary hormone function who suffered postoperative hypopituitarism. Postoperative diabetes insipidus (DI) occurred in 14 patients including 6 patients who had long-term DI and others reporting transient postoperative DI. No cerebrospinal fluid (CSF) leak was identified. There were no deaths or major complications. Obesity developed in 2 patients, with no deaths and recurrent cases during follow-up period. ConclusionThe pure EEE approach is a safe, effective alternative for treatment of recurrent or residual symptomatic craniopharyngiomas owing to its advantages including wide-angle view, close observation and elimination of brain retraction. Larger studies with further follow-up is needed to assess the long-term efficacy of this minimal access approach.