Use Of Endoscopic Endonasal Approach Research Articles

Endoscopic endonasal approach for olfactory groove meningioma resection: Strategies and outcomes in a retrospective case series

ObjectiveThough the endoscopic endonasal approach (EEA) is a widely accepted treatment for skull base tumors, the specific use of EEA for olfactory groove meningiomas (OGMs) is debated, with variable outcomes reported in the literature. We review the surgical results of OGM resections for one surgeon including the operative approach, surgical nuances, and outcomes, with a focus on factors relating to patient selection which favor EEA over transcranial approaches. MethodsWe retrospectively reviewed thirteen cases of endoscopic endonasal resection of olfactory groove meningiomas. Patient characteristics, clinical characteristics, surgical outcomes, and complications were analyzed. Extent of resection was determined based on volumetric analysis of pre- and postoperative MRI. ResultsAnatomic characteristics that render a tumor difficult to access fully are lateral extension beyond the mid-orbit and anterior extension to the falx. Simpson Grade I resection was achieved in 11/13 (84.6 %) cases. Mean pre-operative tumor volume was 8.99 cm3 (range 2.19–16.79 cm3), and 92 % of tumors were WHO grade I. We demonstrate 2 cases of smell preservation, possible with small unilateral tumors and tumors that are confined to either the anterior or posterior portion of the cribriform plate. The post-operative CSF leak rate was 7.7 %, without prophylactic lumbar CSF drainage. The mortality rate was 7.7 % (n = 1) after infectious complications following CSF leak. ConclusionsEndoscopic endonasal resection of olfactory groove meningiomas is an effective and safe operative method with outcomes and complication rates comparable to transcranial approaches. Key considerations include careful patient selection and familiarity with technical nuances of endoscopic endonasal approach for this specific tumor type.

Endoscopic endonasal approach for craniopharyngiomas in children

Background. The incidence of craniopharyngiomas is up to 15 % of intracranial tumors in children. The endoscopic endonasal approach (EEA) is widely spread nowadays and especially for the craniopharyngiomas removal in adults. Nevertheless, this approach is still not so common in pediatric patients. The endoscopic technique significantly improves the visualization of the structures located around the tumor.Aim. To determine the possibilities and limitations for the use of EEA in the treatment of pediatric patients with cranio pharyngiomas.Materials and methods. A total five pediatric patients with craniopharyngiomas were operated via EEA Federal Center of Neurosurgery of Ministry of Health of Russia (Novosibirsk): the age of patients ranged from 4 to 17 years, including 3 boys and 2 girls. All patients at the preoperative stage already had endocrine disorders in one volume or another. Postoperative evaluation of the visual functions showed the improvement in one patient, three patients remained unchanged and one patient developed worthening. In addition, the volume of the sphenoid sinus was studied, the degree of pneumatization of which determines the anatomical accessibility of the tumor.Results. Our experience of the EEA for the craniopharyngiomas in pediatric patients has shown a positive result regarding to the tumor’s gross‑total removal and no data of the tumor recurrence at the follow‑up. According to our results it can be judged that endonasal endoscopic approach for the craniopharyngiomas in pediatric patients could be a method of choice based on the anatomical accessibility of the tumor and its relationships with the critical neurovascular structures.Conclusions. Endoscopic endonasal removal of craniopharyngiomas in pediatric patients can be successfully used when the tumor is anatomically accessible. The experience of using EED in surgery for craniopharyngiomas in children has shown positive results, including a high radical removal of the tumor and the absence of relapses during further follow‑up of patients.

Clival Chordomas in the Endoscopic Endonasal Era: Comparison With Management With Open Skull Base Approaches.

The most significant paradigm shift in surgical management of skull base chordomas has been the adoption of the endoscopic endonasal approach, but the impact on patient outcomes compared with open skull base approaches remains unclear. To compare a large series of patients treated by a single surgeon using primarily endoscopic endonasal approaches with previously published outcomes by the same surgeon using open skull base approaches. Between 2006 and 2020, 68 patients with skull base chordoma underwent resection using primarily endoscopic endonasal approaches. Outcomes and complications were compared with previously published results of resection of chordomas from 1991 to 2005 using open skull base approaches. Compared with the prior cohort, the current principally endoscopic cohort demonstrated similar rates of OS ( P = .86) and progression-free survival ( P = .56), but patients undergoing first-time resection had significantly higher rates of radical resection (82.9% compared with 64.3%, P = .05) and required fewer staged surgeries (9.8% compared with 33.3%, P = .01). There was no difference in survival rates for patients treated in the current era, primarily using endoscopic endonasal techniques, compared with previously published results using open skull-base approaches by the same surgeon. Although use of endoscopic endonasal approach resulted in higher rates of radical resection, patients undergoing first-time resection and fewer staged surgeries were required.

Endoscopic resection of sellar and suprasellar epidermoid cyst: report of two cases and review of literature

Introduction Epidermoid cysts (EC) are lesions developing from neuroectodermal epithelial cells. They represent 1–2% of all intracranial tumors and are usually found in cerebellopontine angle and parasellar regions. To the best of our knowledge, only 27 cases have been reported of EC in sellar and suprasellar region. In 12 cases out of the 27, surgery was done by craniotomy means. The 7 most recent manuscripts (with 15 patients described) share in common the use of endoscopic endonasal approach (EEA) to perform surgical removal. Results In this paper, we report the safe removal of epidermoid cysts arising from the pituitary using an EEA in two patients, which should be the sixth such description in literature. In both cases, resection and evolution was favourable. Discussion Surgical resection is the treatment standard for epidermoid cysts, with total resection including the cyst wall to prevent recurrence when possible. The degree of resection obtained is limited by adherence to nearby neural and vascular structures. The advent of EEA approaches has allowed safe maximal resection especially in midline lesions nearby sellar and suprasellar compartiments.

Analysis on endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach under the microscope for skull base tumor with intra and extra-cranial involvement

Objective: To evaluate the application of combination use of endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically in skull base tumor with intra and extra-cranial involvement. Methods: A total of 7 patients (4 males and 3 females, aging from 27 to 65 years old, with a medium age of 48) undergone complicated skull base surgeries via endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically from May 2016 to January 2018 were reviewed respectively. The patients included 2 cases of recurrent invasive pituitary adenoma, 3 cases of basal skull meningiomas, 1 case of clivus chondrosarcoma, and 1 case of recurrent nasopharyngeal carcinoma. The lesion extensively infiltrated nasal cavity, extending to the paranasal sinus, bilateral cavernous sinus, sellar region, suprasellar, superior clivus, temporal lobe, pterygopalatine fossa, infratemporal fossa and important intracranial vessels. All the 7 patients were treated under general anesthesia by endoscopic endonasal approach combined with frontotemporal orbitozygomatic approach under the microscope. Total excision rate, intraoperative and postoperative complications and postoperative curative effect were observed. All of them were followed up for 6 to 12 months. The Glasgow Outcome Scale (GOS) was used to evaluate the prognosis. Result: Total tumor removal was performed in 5 cases, subtotal removel in 2 cases. There was no complication during the operation. Postoperative severe complications occurred in 2 cases, including 1 case of cerebrospinal fluid rhinorrhea and intracranial infection, which was cured by lumbar cistern drainage and intrathecal injection; 1 case occurred oculomotor nerve paralysis, which recovered during follow-up. Postoperative complications occurred in 1 case of trochlear nerve dysfunction, 2 cases of facial numbness, and 1 case of tinnitus. During follow-up, all patients recovered to varying degrees. There was no bleeding and death after the operation. No tumor recurred during the follow-up period. All patients were recovered well with GOS grade Ⅳ-Ⅴ. Conclusions: Endoscopic transnasal approach combined with microscopic frontotemporal orbitozygomatic approach can remove tumors in one stage, reduce surgical complications and improve surgical effect. It has good application prospects and is suitable for excising complex intracranial and extracranial communicating tumors of widely involving sellar, clivus and petrous apex area.

Endoscopic endonasal surgery for anterior cranial fossa meningiomas.

Meningiomas along the anterior skull base arise from the midline but have historically been resected via open cranial approaches with lateral to medial trajectories. The endoscopic endonasal approach (EEA) offers a direct, inferomedial approach which has demonstrated several superior qualities for their resection. These meningiomas include tuberculum sellae, planum sphenoidale, and olfactory groove meningiomas. While early gross total resection (GTR) was lower than open approaches, EEA has currently achieved comparable rates of GTR and significantly improved postoperative visual outcomes. Rate of cerebrospinal fluid (CSF) leak was one of the early complicating features preventing widespread use of EEA. However, CSF leak rates have dramatically fallen into a tolerable range with introduction of the vascularized nasoseptal flap. Olfactory groove meningiomas often present with anosmia which is persistent after endonasal approach. Rates of other complications have proven similar between EEA and open approaches and include: vascular injury, infection, morbidity, and mortality. With the appropriate team and experience, EEA for anterior skull base meningiomas is increasingly becoming the standard for resection of these lesions. However, there are certain anatomic considerations, patient features, and other aspects which may favor the open approach over EEA, and vice versa; these must be carefully and judiciously evaluated preoperatively. Overall, resection and recurrence rates are comparable, complication rates fall within a very acceptable range, and patients experience superior cosmesis and improved visual outcome with this approach.

Seizure Risk following Open and Expanded Endoscopic Endonasal Approaches for Intradural Skull Base Tumors.

Objectives The incidence of seizures following a craniotomy for tumor removal varies between 15 and 20%. There has been increased use of endoscopic endonasal approaches (EEAs) for a variety of intracranial lesions due to its more direct approach to these pathologies. However, the incidence of postoperative seizures in this population is not well described. Methods This is a single-center, retrospective review of consecutive patients undergoing EEA or open craniotomy for resection of a cranial base tumor between July 2007 and June 2014. Patients were included if they underwent an EEA for an intradural skull base lesion. Positive cases were defined by electroencephalograms and clinical findings. Patients who underwent a craniotomy to remove extra-axial skull base tumors were analyzed in the same fashion. Results Of the 577 patients treated with an EEA for intradural tumors, 4 experienced a postoperative seizure (incidence 0.7%, 95% confidence interval [CI]: 0.002-0.02). Over the same period, 481 patients underwent a craniotomy for a skull base lesion of which 27 (5.3%, 95% CI: 0.03-0.08) experienced a seizure after surgery. The odds ratio for EEA was 0.13 (95% CI: 0.05-0.35). Both populations were different in terms of age, gender, tumor histology, and location. Conclusion This study is the largest series looking at seizure incidence after EEA for intracranial lesions. Seizures are a rare occurrence following uncomplicated endonasal approaches. This must be tempered by selection bias, as there are inherent differences in which patients are treated with either approach that influence the likelihood of seizures.

Preservation of Hypothalamic Function with Endoscopic Endonasal Resection of Hypothalamus-Invaded Craniopharyngiomas

To analyze the preservation of hypothalamic function using the endoscopic endonasal approach (EEA) in a single-center clinical series of patients with hypothalamus-invaded craniopharyngioma (CP) and compare this series with reported cases by the open transcranial approach (TCA). A retrospective review of hypothalamus-invaded CP surgical cases treated with EEA was performed. Hypothalamic damage was evaluated in terms of the body mass index (BMI), endocrine status, and quality of life before and after surgery. A review of the available literature reporting the use of EEA and TCA over the last decade was performed for comparison. In total, 63 cases amenable to EEA were investigated. The elevation in BMI was substantial and an increase in BMI greater than 9% was observed in 22 patients (34.92%). Most patients exhibited a BMI gain >9%within 3 months postoperatively. A total of 16 of the 19 patients who had normal anterior pituitary function preoperatively worsened after surgery. Of the 27 cases reporting preoperative partial hypopituitarism, 16 cases worsened postoperatively and 11 cases remained unchanged. All 9 cases with preoperative panhypopituitarism remained unchanged postoperatively. A total of 40 new cases developed diabetes insipidus, and 3 of the 10 patients with preoperative diabetes insipidus exhibited resolved at the latest follow-up. The quality of life showed no significant difference. EEA can achieve greater gross total resection than TCA when performed by an experienced surgeon. Combined with the reduced postoperative hypothalamic damage in our patients with only hypothalamus-invaded CP, especially the shortened time horizons of hypothalamic obesity development and reduced percentage of patients with obesity, the EEA technique should be a preferred alternative over TCA.

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

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

Endoscopic Endonasal Surgery for Cranial Base Chondrosarcomas.

Microsurgical resection via open approaches is considered the main treatment modality for cranial base chondrosarcomas (CBCs). The use of endoscopic endonasal approaches (EEAs) has been rarely reported. To present the endoscopic endonasal experience with CBCs at our institution. Retrospective review of the medical records of 35 consecutive patients who underwent EEA for CBC resection between January 2004 and April 2013. Surgical outcomes and variables that might affect extent of resection, complications, and recurrence were analyzed. Forty-eight operations were performed (42 EEAs and 6 open approaches). Gross-total resection was achieved in 22 patients (62.9%), near total (≥90% tumor resection) in 11 (31.4%). Larger tumors were associated with incomplete resection in univariate and multivariate analysis ( P = .004, .015, respectively). In univariate analysis, tumors involving the lower clivus and cerebellopontine angle were associated with increased number of complications, especially postoperative cerebrospinal fluid leak ( P = .015) and new cranial neuropathy ( P = .037), respectively. Other major complications included 2 cases of meningitis and deep venous thrombosis, and 1 case of hydrocephalus and carotid injury. Involvement of the lower clivus, parapharyngeal space, and cervical spine required a combination of approaches to maximize tumor resection ( P = .017, .044, .017, respectively). No predictors were significantly associated with increased risk of recurrence. The average follow-up time was 44.6 ± 31 months. EEAs may be considered a good option for managing CBCs without significant posterolateral extension beyond the basal foramina and can be used in conjunction with open approaches for maximal resection with acceptable morbidity.

Objective sinonasal functional outcomes in endoscopic anterior skull-base surgery: an evidence-based review with recommendations.

The use of endoscopic endonasal approaches to the anterior skull base has dramatically expanded in recent years, with clinical endpoints and complication rates that compare favorably to traditional approaches. The impact of the endoscopic approach on sinonasal function has been less rigorously evaluated. The purpose of this study was to systematically analyze the literature evaluating objective sinonasal outcomes in endoscopic anterior skull-base surgery, and provide evidence-based recommendations. A systematic review of the literature was performed based on a published guideline for developing an evidence-based review with recommendations. Objective sinonasal outcomes included were olfaction, mucociliary clearance, and nasal airflow. Ten articles were identified addressing objective olfactory outcomes: 2 randomized controlled trials; 6 cohort studies; and 2 retrospective case series. One cohort study investigating mucociliary clearance was identified. Six studies reporting postoperative endoscopic outcomes were identified. Based on the available evidence, nasoseptal flap (NSF) elevation with or without use in reconstruction likely leads to impairment in objective olfactory function. Endoscopic sellar and parasellar surgery without the elevation of an NSF may lead to a transient reduction in olfactory function. In the absence of a high a priori risk of cerebrospinal fluid (CSF) leak, it is an option to avoid routine NSF elevation in sellar and parasellar procedures, with preservation of at least 1 vascular pedicle during the approach. Monopolar electrocautery for mucosal incisions may increase the risk of olfactory impairment. If an NSF is used, donor site defect reconstruction may be considered.

Endoscopic surgery for tuberculum sellae meningiomas: a systematic review and meta-analysis

Recent reports of surgical resection of tuberculum sellae meningiomas through an endoscopic endonasal approach (EEA) have provided an alternative to transcranial approaches in selected cases. However, these published reports have been limited by small sample size from single institutions. We performed a systematic review and meta-analysis to gain insight into potential limitations and benefits of EEA for tuberculum sellae meningiomas. We performed a systematic review of the literature and analyzed pooled data for descriptive statistics on short-term morbidity and outcomes. We compared EEA to transcranial approaches reported during the same time-frame. Six studies (49 patients) met inclusion criteria for EEA. A pooled analysis of transcranial results reported during a similar time period yielded 11 studies (412 patients). There were no differences in rate of gross total resection or peri-operative complications between the two groups. Although the EEA group was associated with higher rates of CSF leak (p < 0.05; OR 3.9; 95% CI 1.15, 15.75), EEA were also associated with significantly higher rates of post-operative visual improvement compared to transcranial approaches (p < 0.05; OR 1.5; 95% CI 1.18, 1.82). A systematic review of the small series of EEA for tuberculum sellae meningiomas published to date revealed similar extent of resection and morbidity, but increased post-operative visual improvement compared to transcranial approaches during a similar time period. Long-term follow-up will be needed to define recurrence rates of EEA as compared to transcranial approaches. Cautious use of EEA for the removal of smaller tuberculum sellae meningiomas after formal endoscopic training may be warranted.

Endoscopic craniofacial resection for pediatric esthesioneuroblastoma

Abstract Pediatric esthesioneuroblastomas are rare tumors with only about 100 reported cases. Standard surgical treatment is the open craniofacial resection. Pre-treatment imaging is critical for planning, and surgery remains the primary treatment modality followed by adjuvant therapy. We report a 12-year-old female who underwent endoscopic-assisted resection of an extensively calcified Kadish C and Dulguerov–Calcaterra T3N0M0 esthesioneuroblastoma. Following radiation therapy, she is disease-free 18 months post-treatment. Although there are few reported cases in pediatric patients, our case supports the use of endoscopic endonasal approaches for select pediatric skull base malignancies.

Indications and Limitations of Endoscopic Skull Base Surgery

A wealth of critical neurovascular structures within a relatively small surface area adds to the already intricate nature of skull base surgery. Surgical approaches to the area are difficult and often associated with significant morbidity and mortality. During the past two decades, endoscopic endonasal approaches (EEAs) have evolved to access the ventral skull base for the resection of tumors (benign and malignant), the decompression of neural structures including the cervicomedullary junction (pannus from rheumatoid arthritis or congenital anomalies, such as platybasia) and the reconstruction of skull base defects (cerebrospinal leaks, meningoencephalocele). These minimal access approaches obviate the need for external incisions, translocation of maxillofacial bones and retraction of the brain. Furthermore, EEAs yield improved visualization, which may reduce complications, and improve quality of life outcomes. Anatomical difficulties (e.g., vascular encasement or extension beyond the plane of a major vessel or cranial nerve), various special conditions (e.g., pediatric patients and vascular tumor) and limitation of institutional resources and technical difficulties may limit the use of EEAs. Thus, one should understand the indications and limitations of EEAs to optimize patient selection, which, in turn, may lead to superior surgical outcomes and reduced morbidity.