Transnasal Endoscopic Resection Research Articles

Endoscopic endonasal approach for skull base chordoma

BackgroundChordoma is a rare slow-growing malignant bone tumor that arises from embryonic notochordal remnants in the axial skeleton. Clival chordomas have a high propensity for extension through the skull base and a high proclivity for recurrence. Recently, resection of skull base chordomas through the endoscopic transnasal approach has become the standard way of managing these lesions with the new advancements in neuronavigation and reconstructive techniques in skull base surgery.MethodsIt is a retrospective study of all patients with clival chordoma that were operated upon using endoscopic endonasal resection at the Main Alexandria University Hospital during the period from March 2008 to April 2013. The extent of surgical resection was assessed intraoperatively and confirmed by the postoperative MRI study performed 8–12 weeks, 6 months, and yearly after the surgery.ResultsTwelve patients with clival chordoma were managed by endoscopic transnasal resection. Gross total resection confirmed by postoperative MRI was achieved in four cases, subtotal resection in six cases, and partial resection in two cases of clival chordoma. In cases where gross total resection was not achieved, residual tumors were adherent to vital neurovascular structures as confirmed with the utilization of an intraoperative imaging navigation device. A study of postoperative complications and possible recurrence was done for all cases.ConclusionsThe findings of this study highlight the significance of gross total resection as a major determinant for preventing the recurrence of chordoma. Our findings also support the validity of the endoscopic approach for the management of clival chordoma especially when the approach is tailored based on the site and extent of the tumor.

Intraoperative prevention of nasal mucosal injury and surgical field contamination during single-nostril transnasal endoscopic pituitary adenomas resection.

The common complications of transnasal endoscopic pituitary adenomas resection include nasal hemorrhage, olfactory disorder, nasal adhesion, and intracranial infection. Consequently, the protection of nasal mucosa and the prevention of surgical field contamination are critical. We presented a step-by-step description of the methods of the disinfection and protection of nasal mucosa and the prevention of surgical field contamination during transnasal endoscopic pituitary adenomas resection, and these comprehensive measures to prevent these complications have not been documented. These measures effectively reduce the risk of nasal mucosal injury and surgical field contamination, and are easy to perform.

Endoscopic transnasal resection of clival meningiomas

Surgical treatment of ventral and ventrolateral meningiomas of posterior cranial fossa is difficult in modern neurosurgery. This is due to peculiarities of approach to these areas and concentration of critical structures (cranial nerves and great vessels). Currently, endoscopic transnasal approach to these meningiomas allows partial, and in some cases, total resection. However, this technique is not widespread. To analyze the world literature data on postoperative outcomes in patients with clival and petroclival meningiomas after endoscopic transnasal resection. We analyzed 22 articles representing treatment of 61 patients with clival and petroclival meningiomas. Total or near-total resection was achieved in 22.9% of cases, subtotal resection - 40.9%, partial resection - 26.2% (data were not provided in other cases). Even partial and subtotal resection leads to significant regression of symptoms. Endoscopic transnasal surgery is a full-fledged alternative to transcranial approaches in surgical treatment of clival meningiomas. It is also an additional option for patients with petroclival meningiomas after ineffective transcranial approaches. Transnasal tumor shrinkage and devascularization lead to brainstem decompression, regression of hydrocephalus and baseline clinical symptoms.

Staged Intracranial Free Tissue Transfer and Cranioplasty for a Refractory Nasal-cranial Base Fistula

Summary: After a transnasal endoscopic resection of a high-grade adenoid cystic carcinoma that underwent adjuvant chemoradiation, there was delayed recurrence managed by en bloc resection through an open craniofacial approach. Subsequently, the patient developed a chronic nasocranial fistula with secondary infection and bone flap resorption. This resulted in infectious episodes with secondary scalp incisional dehiscence and hardware exposure which required multiple bone debridement procedures, hardware removal, prolonged IV antibiotics, and hyperbaric oxygen treatment. The nasocranial fistula and chronic frontal bone osteomyelitis persisted despite the previous interventions. The patient underwent a frontal bone removal and obliteration of the anterior cranial base fistula with a free vastus lateralis muscle flap. At 4 weeks postoperatively, the intranasal portion of the muscle flap had completely mucosalized. After a 6-week course of IV antibiotics, a secondary cranioplasty using a custom-made poly-ether-ether-ketone implant was performed. The patient remained disease- and infection-free for the duration of follow-up (17 months).

A cross-sectional study of hybrid reconstruction of the anterior skull base following extended endoscopic transnasal resection of skull base tumours

A cross-sectional study of hybrid reconstruction of the anterior skull base following extended endoscopic transnasal resection of skull base tumours

Carcinosarcoma: a rare sinonasal malignancy with atypical behaviour

Carcinosarcoma is an extremely rare neoplasm in the nasal cavity and in the paranasal sinus, with rapid growth and extensive local destruction. We report a case of a 61-year-old man with progressive left-side nasal obstruction and epiphora for six months. Imaging showed a massive mass lesion, mainly located in the left nasal cavity and ethmoid sinus, with no intracranial or orbital extension. Biopsy of the nasal mass revealed a poorly-differentiated squamous cell carcinoma associated with sarcomatous elements. Patient underwent an endoscopic transnasal resection. Definitive histopathologic analysis revealed a carcinosarcoma. Postoperative radiotherapy was, then, performed. After five years of follow-up, there is no evidence of tumor recurrence. This report highlights that even though despite the lack of optimal treatment protocol, long term disease control can be achieved through endoscopic transnasal resection complemented with radiotherapy.

Prognostic factors in transnasal endoscopic surgery for paediatric patients with ossifying fibroma of the paranasal sinuses and skull base

BackgroundOssifying fibroma of the paranasal sinuses and skull base in paediatric patients is difficult to operate and can recur easily after surgery. This study aimed to analyse factors associated with recurrence after transnasal endoscopic resection of ossifying fibroma in paediatric patients.MethodsThis retrospective observational study included 34 patients under 17 years of age who underwent transnasal endoscopic resection of ossifying fibroma of the paranasal sinuses and skull base from 2005 to 2021 at a single tertiary medical centre. Clinical indicators such as age; surgical history; pathological type; intraoperative bleeding; and orbit, anterior skull base, sphenoid bone, sella turcica, clivus, or frontal sinus involvement were subjected to univariate analysis using the χ2 test, to investigate whether any of these factors affected recurrence.ResultsAll 34 patients underwent transnasal endoscopic resection. The follow-up period was 6–120 months (mean: 48.0 months). Five patients experienced local recurrence during the follow-up period (14.7%). Results of χ2 tests indicated that a history of previous surgery, the amount of intraoperative bleeding, and sphenoid and/or sella turcica and clivus involvement were significantly associated with recurrence (P < 0.05). Age; pathological stage; and orbit, anterior skull base, and frontal sinus involvement were not associated with recurrence (P > 0.05).ConclusionsThe increased risk of recurrence after transnasal endoscopic resection of nasal–skull base ossifying fibroma should be considered during endoscopic surgery in paediatric patients with a history of previous surgery, intraoperative bleeding tendency, and sphenoid and/or sella turcica and clivus involvement. These patients require careful postoperative follow-up.

Bleeding septal polyp, a rarity becoming common – A report of four cases

Bleeding septal polyp is a benign, previously assumed very rare lesion that usually presents as unilateral epistaxis, nasal blockage, and intranasal mass. It can occur spontaneously or posttraumatic. We report four cases of three young adult females and one pediatric male. All of them presented with recurrent, spontaneous, torrential, unilateral epistaxis with progressive unilateral nasal blockage of varied durations. Anterior rhinoscopy was done in all cases, and it revealed a polypoidal mass in the cartilaginous septum and ulcerated mucosa in some cases that easily bleeds on contact. A clinical diagnosis of a bleeding septal polyp was made. Patients were evaluated and underwent excisional biopsy using the transnasal endoscopic resection technique. Histology revealed hemangiomatous lesions for the females and angiofibroma for the male. They were followed up for 6 months, with complete healing of the excision site and without any complaint. Bleeding septal polyp is becoming a common cause of spontaneous, recurrent unilateral epistaxis. This case report is an addition to the literature to increase awareness in clinical practice.

ODP288 A Cautionary Tale of Two Endocrine Emergencies- A Patient with Pituitary Macroadenoma Presenting with Acute Adrenal Crisis Leading to Pituitary Apoplexy

Abstract A 56 year old male with history significant for myasthenia gravis, non-functional pituitary macroadenoma and age related macular degeneration (ARMD), who presented to the hospital with 3 days of diplopia, nausea, vomiting, generalized weakness, and bitemporal headaches. Two months prior to presentation, he was diagnosed with an idiopathic disseminated rash for which he was treated with high dose steroids. Steroids were tapered rapidly and stopped abruptly 4 days ago. Initial presentation was significant for hypotension with BP of 95/64, hyponatremia [sodium 127(136 - 145 mmol/L)], chloride was 90 (98 - 107 mmol/L), potassium 5.9 (3.4 - 5.3 mmol/L) consistent with acute adrenal crisis. He was immediately initiated on high dose Solu-Cortef and intravenous fluids. Of historical significance was new visual field deficit which had occurred in the background of his existing ARMD. This raised the suspicion for pituitary apoplexy. MRI pituitary showed enlarging pituitary adenoma (2.1×2. 0×2.6 cm from 1.6×1.6×2.3 cm 5 months prior) with necrotic changes and internal signal complexity. Ophthalmology was consulted stat and on confirmation of new right optic neuropathy, urgent surgical decompression was performed via transnasal endoscopic resection of pituitary tumor by neurosurgical and ENT team. Further lab testing revealed secondary adrenal insufficiency and pan hypopituitarism. Patient's vision recovered remarkably well post operatively and he was initiated on thyroid hormone supplementation in addition to continuing steroids. He was discharged with recommendations to follow up with endocrinology outpatient for further management. Conclusion Pituitary apoplexy although well known can easily be missed clinically without a high degree of suspicion. While our patient presented with acute adrenal crisis leading to some of the presenting complaints, his new visual field deficits were unaccounted for. This case highlights the importance of a through history and examination to delineate between acute and chronic visual field symptoms especially in the background of pre-existing retinal diseases. Secondly, although the patient's adrenal insufficiency could be due to apoplexy, we hypothesize that it is more likely that it could have resulted due to abrupt discontinuation of high dose steroids leading to adrenal crisis. The fluctuation in BP in turn could have triggered an apoplectic event in an otherwise stable macroadenoma leading to two independent but interrelated endocrine emergencies. Presentation: No date and time listed

PMON122 Unveiling the Kraken- An Incidentally Found Silent Corticotroph Adenoma of the Pituitary Gland

Abstract Introduction Silent corticotroph adenomas (SCA) are an unusual and rare variant of non- functioning pituitary adenomas (NFA) that do not produce biochemical hypercortisolism or clinical Cushing's disease (CD), yet stain strongly for ACTH on immunohistochemistry. They represent 3-19% of non-functioning adenomas and 20% of corticotroph producing adenomas. SCAs are distinguished by their late presentation, frequent cavernous sinus involvement and earlier recurrence requiring multimodal management. Case We present a case of a 70 year old female with a remote history of breast cancer (2002) and uterine cancer (2016) in remission who was found to have an incidental soft tissue mass in the sella turcica on CT head after a fall in 2021. An MRI brain confirmed the mass as a 1.8×2.0×1.5 cm pituitary lesion with expansion to the sella. Patient had no symptoms related to pituitary hyperfunction or mass effect. Biochemical workup including IGF-1, prolactin, LH, FSH, and AM Cortisol level were all within normal limits. Ophthalmologic evaluation was normal. Repeat pituitary MRI 2 months later showed increasing homogeneously enhancing lesion on the left petrous ridge measuring 2.8×2.8×1.3 cm. There was extension into the cavernous sinus with involvement and encasement of the carotid artery. After multi-disciplinary evaluation including neurosurgery and ENT, patient elected to undergo transnasal endoscopic resection of pituitary tumor. The tumor was only partially resected due to its close association with the carotid artery. Final pathology was significant for monotonous proliferation of tumor cells with small round nuclei and amphophilic cytoplasm, characteristic of a pituitary adenoma. The tumor cells stained strongly positive for ACTH, and negative for all other hormone receptors. Further endocrine workup showed normal morning cortisol and ACTH and marginally elevated 24 hour urine cortisol measuring 47.6 mcg/g creatinine (ULN 42.3). Her clinical presentation was consistent with a SCA. A Dotatate PET/CT was ordered to be performed 3 months postoperatively to assess for SSTR receptors for potential targeted therapy against the residual tumor. Discussion We present the case of an elderly female who was incidentally found to have an invasive SCA precluding its complete resection. There are multiple theories regarding the lack of biological activity of SCAs including lack of enzyme in the tumor to cleve the active ACTH from the prohormone state, dysfunctional lysosomal activity leading to destruction of ACTH before secretion, origin from POMC positive pars intermedia cells instead of true corticotropic cells. These tumors have an increased rate of tumor invasion and recurrence making them difficult to treat. A potential targeted treatment may be somatostatin receptor ligands which will be seen on the dotatate PET/CT. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Transnasal Endoscopic Resection of Torus Tubarius Pleomorphic Adenoma

Pleomorphic adenoma is the most common benign tumor of the salivary glands. Pleomorphic adenoma mainly occurs in the major salivary glands and less in the minor salivary gland. If pleomorphic adenoma occurs in the minor salivary glands, the most commonly found site is the palate. In addition, it can be developed from lip/cheek, tongue, nasal cavity, larynx and the nasopharynx. Pleomorphic adenoma rarely occurs in the nasopharynx, especially torus tubarius. We present a rare case of pleomorphic adenoma originating from torus tubarius in the nasopharyngeal cavity treated successfully via transnasal endoscopic resection.

Endoscopic Transnasal Resection for Chordoma Invaded to Lower-Third Clivus-Usefulness of Preoperative Simulation With Virtual Endoscopic Imaging: 2-Dimensional Operative Video.

Endoscopic Transnasal Resection for Chordoma Invaded to Lower-Third Clivus-Usefulness of Preoperative Simulation With Virtual Endoscopic Imaging: 2-Dimensional Operative Video.

Surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base

Objective:To investigate the surgical approach of transnasal endoscopic resection of benign lesions in the paramedian lateral skull base. Methods:Retrospectively analyze 40 cases of the clinical data of patients with benign lesions of the skull base from August 2018 to February 2021 with transnasal endoscopic surgery, including 9 cases of cholesteatoma, 6 cases of hemangioma, 1 case of hemangiopericytoma, 6 cases of schwannoma, 15 cases of sphenoid sinus lateral crypt meningocele and cerebrospinal fluid leak, 3 cases of nasopharyngeal carcinoma bone inflammation after radiotherapy. All patients underwent transnasal endoscopic surgery, and different surgical approaches were selected according to the lesion location. Results:The total resection rate was 100% in 40 patients. One patient had cerebrospinal fluid rhinorrhea, which was cured after repair. During the follow-up period of 3-30 months, 39 patients had different degrees of numbness in the maxillary or mandibular region, and the numbness disappeared from 2 weeks to 6 months; one patient with schwannoma still had numbness on one side of the upper lip one year after surgery. Conclusion:Transnasal endoscopic resection of benign lesions in the paramedian skull base has a high surgical safety and cure rate. The surgical approach selection mainly focuses on the pterygoid process and extends to the periphery. The shortest and least damaging approach should be selected according to the lesion location, and the endoscopic approach should also be selected according to the surgeon's expertise.

Transnasal endoscopic resection of nasal chondromesenchymal hamartoma in infancy: an analysis of 5 cases

BackgroundNasal chondromesenchymal hamartomas (NCMHs) are extremely rare benign tumors that most commonly affect children in the first year of life. The purpose of this study was to investigate and summarize the characteristics of NCMH cases and the efficacy of transnasal endoscopic resection of NCMHs.MethodsThis is a retrospective study including 5 cases of infant diagnosed as NCMH between April 2016 and April 2020. Diagnostic techniques include nasoendoscopy, computerized tomography (CT) scan, magnetic resonance imaging (MRI) with contrast and microscopic and immunohistologic studies. Data collected included patient demographics, patient symptoms, radiographic findings, characteristics of tumor growth, follow-up time, recurrence, and postoperative complications.ResultsIn 5 cases, 3 were males and 2 were females who aged 1, 2, 3, 6 months and 1 year, respectively. The size of the mass measured 1.6 cm*1.9 cm*1.8 cm at its smallest and largest was 4.0 cm*3.5 cm*3.0 cm. All five patients underwent tumor resection via transnasal endoscopic approach. Four tumors were completely removed, and one underwent partial resection, which was completely resected by midfacial degloving operation 13 months after the first surgery. There was no postoperative complication. The current postoperative follow-up period was 1 to 4 years, and no recurrence has been observed.ConclusionsComplete surgical resection of NCHM is necessary to resolve the symptoms and prevent recurrence. Transnasal endoscopic approach is a safe and effective choice for pediatric NCMH patients.

The effect of dexmedetomidine compound nicardipine in transnasal endoscopic pituitary tumor resection

Objective: To compare the effect of dexmedetodeidine and nicardipine alone in transnasal endoscopic pituitary tumor resection, and to find a more suitable controlled antihypertensive regimen. Methods: 40 patients under elective general anesthesia (ASA grade I to I I) were randomly divided into nicardipine group (N group) and dexmedetomidine + nicardipine group (D 0 group), 2 N group). It was the same, before anesthesia initiation (T0), 10min after pumping nicardipine (T1), 20min after (T2), 30min later (T3), 10min after stopping pumping (T4), 20min after (T5), heart rate. Surgical field quality score, bleeding volume, propofol, remifentanil, and nicardipine dosage, respiratory recovery time, extubation time, and adverse effects were recorded. Results: At the 20min time (T4) time, the MAP value of DN group was significantly lower than that of N group, and the difference was statistically significant (P &lt;0.05).At the three moments of 30min (T2), stop pumping (T3) and 20min (T4), the HR value of DN group was lower than group T, and the difference was statistically significant (P &lt;0.05). Both DN and N achieved good surgical field, with no significant differences in anesthesia depth, operation time and bleeding time (P&gt; 0.05); respiratory recovery time in DN was shorter than group N (P &lt;0.05).The incidence of adverse reactions of chills and agitation was higher in the group N than in the DN group, and the difference was statistical significant (P &lt;0.05).Conclusion: separate application of nicardipine in transnasal endoscopic pituitary resection antihypertensive effect is positive, but dexmedetomidine compound nicardipine application in this operation, can reduce propofol, remifentanil anesthetic dosage, heart rate is more stable, also can reduce the incidence of postoperative chills, agitation, than separate application of nicotinate usual effect is better.

A Rare Case of Rathke’s Cleft Cyst Apoplexy

The occurrence of symptomatic Rathke's cleft cyst (RCC) apoplexy is extremely rare. This is often misdiagnosed due to similar presentations to subarachnoid haemorrhage and pituitary apoplexy. This case highlights an excellent example of similar clinical presentation and serves as a learning case for clinicians. A 40-year-old lady presented to a district hospital with 9 days of worsening severe headache associated with blurring of vision, photophobia, stiff neck, nausea and vomiting. Nuchal rigidity and Brudzinski’s positive. Blood test showed hyponatremia, raised inflammatory markers and normal dynamic pituitary function test. CT Head demonstrated no evidence of space-occupying lesion or intracranial haemorrhage. Lumbar puncture showed xanthochromia positive consistent with subarachnoid haemorrhage. MRI head advised by Neurosurgery team and revealed a focal lesion involving anterior pituitary macroadenoma with mass effect on optic chiasm with possible haemorrhage within. Further assessment in tertiary hospital confirmed loss of visual acuity and field deficit. Patient underwent emergency endoscopic transnasal transsphenoidal resection of apoplectic tumour and repair of CSF leak with graft from thigh. Histopathology report showed a Rathke’s cleft cyst with squamous metaplasia. Post operatively, the patient developed sinusitis which fully recovered, and MRI showed good decompression. The author demonstrated a rare case of symptomatic RCC which was initially presumed to be pituitary apoplexy. Radiology imaging and treatment approach for both conditions are quite similar and can only be differentiated by histopathology. Further research is required to identify the causes and risk factors of RCC apoplexy to aid early detection and diagnosis.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S23

Effect analysis on endoscopic transnasal resection of epidural cholesteatoma at paracentral skull base

Objective: To indicate the clinical features of endoscopic transnasal resection of epidural cholesteatoma at paracentral skull base and to analyze its efficacy. Methods: The total excision rate, postoperative complications and postoperative curative effect of 7 patients (4 males and 3 females, aging from 32 to 63 years old) who underwent middle skull base surgery for epidural cholesteatoma resection under transnasal endoscope at Tianjin Huanhu Hospital between August 2017 and August 2020 were retrospectively reviewed. All patients were followed up for 6 to 36 months. The postoperative MRI, clinical symptoms and recurrence were reviewed. Descriptive statistical methods were used for analysis. Results: Among the 7 patients, there were total resection (complete resection of cyst contents and capsule) in 4 patients, near-total resection (complete resection of cyst contents, incomplete resection of cyst capsule) in 1 patient, and subtotal resection (incomplete resection of cyst contents and capsule) in 2 patients. The clinical symptoms of all patients were improved postoperatively with 1 patient who had no clinical symptoms. One case had postoperative cerebrospinal fluid rhinorrhea, which was cured after lumbar drainage and nasal iodoform gauge packing. Up to now, 7 patients (including patients with partial resection) had no recurrence. Conclusion: Endoscopic transnasal approaches may be effectively used for resection of epidural cholesteatoma in the paracentral skull base in carefully selected cases.

Endoscopic Transnasal Resection of Adenoid Cystic Carcinoma of the Nasal Septum: A Case Report and Literature Review

Very few reports have described adenoid cystic carcinoma of the nasal septum. We performed endoscopic endonasal surgical resection of an adenoid cystic carcinoma of the nasal septum in a 61-year-old woman. Histological examination confirmed adenoid cystic carcinoma. The patient has had no local recurrence or distant metastases as of 3 years postoperatively.

Transnasal Endoscopic Resection of a Huge Solitary Fibrous Tumor Originated From Frontal Recess

Solitary fibrous tumor (SFT) is a spindle cell neoplasm that occurs commonly in the pleural space. One-third of SFTs arising from an extrathoracic organ are found in the head and neck region, and they arise rarely in the sinonasal tract. Most of these tumors are benign, but malignant tumors are identified in some cases. Here we report a rare sinonasal SFT arising from the frontal recess. A 32-year-old male patient with chief complaint of headache and left facial pain visited the outpatient clinic. He had suffered from paranasal pain and nasal obstruction for several months, and symptoms became more severe in the previous three months. The mass rapidly increased in size and was protruding from the left nostril when he visited the hospital. After computed tomography and magnetic resonance imaging scans, transnasal endoscopic resection of the tumor was performed, and gross total tumor removal was successfully achieved. We believe this case will be helpful for providing information regarding management of such uncommon huge sinonasal tumors originating from the frontal recess.

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 .