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Lateral sphenoid sinus encephalocele. Encephaloceles are managed by first placing a lumbar drain and instilling a dilute solution of fluorescein intrathecally. This allows for definitive indentification of the encephalocele and site of CSF drainage endoscopically. The encephalocele is followed back to the skull base dehiscence with suction and bipolar cautery and then bony defect is exposed and cleaned. A strut of cartilage and bone is then placed across the bony defect and then a mucosal graft is placed as an onlay graft and then tissue glue and merocel sponges are used to secure the graft in place. In this picture, the bipolar was placed through a transpterygoid port and the fluorescein is clearly seen as well as the carotid canal.
Source publication
Endoscopic skull base surgery has undergone rapid advancement in the past decade moving from pituitary surgery to suprasellar lesions and now to a myriad of lesions extending from the cribriform plate to C2 and laterally out to the infratemporal fossa and petrous apex. Evolution of several technological advances as well as advances in understanding...
Similar publications
Learning Objectives 1) Describe a technique used in the repair of large skull base defects 2) Understand the indications for a combined multilayer ADA and NSF repair for anterior skull base defects 3) Evaluation the rate of postoperative CSF leak following endoscopic endonasal resection of the cribriform plate.
Background: The aim of this study was to establish the morphometry and sexual dimorphism of laterallamella of cribriform plate in the North Karnataka region.Method: Six hundred and forty four (644) Multidetector computed tomographic scans were collectedfrom North Karnataka region and analyzed by using RadiAnt DICOM Viewer. The thickness andangulati...
Meningoencephalocele is a rare condition that results due to defect in skull base causing brain tissue to herniate along with meninges. We present a case of posttraumatic meningoencephalocele in an 11-year-old child, who presented with nasal mass and cerebrospinal fluid leak. A cribriform plate defect was detected on magnetic resonance imaging alon...
Purpose
The computed tomography (CT) study investigates the olfactory fossa (OF) morphometry and morphology.
Methods
Fifty Greek adult dried skulls were macroscopically investigated for the detection of the OF morphological patterns and after a multiplanar CT reconstruction, the OF morphometry was accurately calculated using a digital ruler.
Resu...
Objective: to determine the AEA anatomy and variations by computed tomography (CT) in adult and their relations to and presents new AEA classifications. Methods: 150 Paranasal CT scans (300 sides) were included. Axial images were acquired with multiplanar reformates to obtain delicate details in coronal and sagittal planes. Results: 144 AEAs canal...
Citations
... Transnasal endoscopic approaches for pituitary pathologies and skull base tumors are routinely used nowadays as a substitution of a more traumatic external approach, with a better aesthetic result 11,12 . However, the application of this technique is limited in pediatric cases, it has also proved to ...
Brain abscess is a rare but life-threatening infection of the brain. It often occurs as a complication of infection, trauma, or surgery. This case presents a brain abscess in a 22-month-old boy that developed after a transnasal injury with a foreign body. A minimal-invasive, transnasal, endoscopic-controlled technique was used, during which the foreign object was removed and the abscess drained. Bacteriological samples were obtained and the abscess cavity irrigated. Postoperative care included antibiotics and daily irrigation of the abscess cavity. Follow-up MRI scans showed reduction in abscess size. A spinal drain was inserted temporarily to address rhino-liquorrhoea. The patient remained asymptomatic during one-year of follow-up. This case report highlights the occurrence of a brain abscess in childhood following a transnasal injury and demonstrates a minimal-invasive, transnasal, endoscopic-controlled surgical technique. The findings underscore the importance of considering brain abscess as a potential complication in cases of head trauma, particularly in atypical presentations.
... However, access to cadaver laboratories is a limiting factor in most of developing countries including India. Recent data suggests approximately 112 public sector healthcare institutions are having training courses in neurosurgery and barring 7-8, none has the facility of cadaver dissection even for basic neurosurgical training [6]. ...
Skull base dural reflections are complex, and along with various ligaments joining sutures of the skull base, are related to most important vessels like internal carotid arteries (ICA), vertebral arteries, jugular veins, cavernous sinus, and cranial nerves which make surgical approaches difficult and need thorough knowledge and anatomy for a safe dissection and satisfactory patient outcomes. Cadaver dissection is much more important for the training of skull base anatomy in comparison to any other subspecialty of neurosurgery; however, such facilities are not available at most of the training institutes, more so in low- and middle-income countries (LMICs). A glue gun (100-Watt glue gun, ApTech Deals, Delhi, India) was used to spread glue over the superior surface of the bone of the skull base over desired area (anterior, middle, or lateral skull base). Once glue was spread over the desired surface uniformly, it was cooled under running tap water and the glue layer was separated from the skull base. Various neurovascular impressions were colored for ease of depiction and teaching. Visual neuroanatomy of the inferior surface of dural reflections of the skull base is important for understanding neurovascular orientations of various structures entering or exiting the skull base. It was readily available, reproducible, and simple for teaching neuroanatomy to the trainees of neurosurgery. Skull base dural reflections made up of glue are an inexpensive, reproducible item that may be used for teaching neuroanatomy. It may be useful for trainees and young neurosurgeons, especially at resource-scarce healthcare facilities.
... Recent data suggests approximately 112 public sector healthcare institutions are having training courses in neurosurgery and barring 7-8, none has facility of cadaver dissection even for basic neurosurgical training. [2] Authors use arti cial models of skull base dural re ections for training of trainees and young neurosurgeons and describe the technique of the same. It may be useful for skull base surgery training at resource scarce centres, especially those without cadaver dissection facilities, around the world. ...
Background
Skull base dural reflections are complex, and along with various ligaments joining sutures of skull base, are related to most important vessels like internal carotid arteries (ICA), vertebral arteries, jugular veins, cavernous sinus and cranial nerves make surgical approaches difficult and needs thorough knowledge and anatomy for safe dissection and satisfactory patient outcomes. Cadaver dissection is much more important for training of skull base anatomy in comparison to any other subspecialty of neurosurgery, however, such facilities are not available at most of the training institutes more so in low and middle income countries (LMICs).
Methods
A glue gun (100-watt glue gun, Aptech deals, Delhi, India) was used to spread glue over the superior surface of bone of skull base over desired area (anterior, middle or lateral skull base). Once glue was spread over the desired surface uniformly, it was cooled under running tap water and the glue layer was separated from the skull base. Various neurovascular impressions were colored for ease of depiction and teaching.
Result
Inferior surface of dural reflections of the skull base is important for understanding neurovascular orientations of various structures entering or exiting the skull base. It was readily available, reproducible and simple for teaching neuroanatomy to the trainees of neurosurgery.
Conclusion
Skull base dural reflections made up of glue is an inexpensive, reproducible item which may be used for teaching neuroanatomy. It may be useful for trainees and young neurosurgeons especially at resource scarce health-care facilities.
... Endoscopic resection of skull base surgery had gained signifi cant improvement widely all over the world. 1 After the development of Hopkin rod endoscopic high-defi nition cameras, such surgery has become more feasible and accurate. A computerized tomography scan is a helpful tool in detecting important anatomical bony landmarks and helps in further planning and navigating the surgery accurately to minimize complications. 2 It also provides important information about location and extension of lesions to allow better surgical planning and patient management. ...
Endoscopic sinus and skull base Surgery has gained significant improvement widely all over the world. A computerized tomography (CT) scan provides a detailed anatomy of the skull base especially the bone framework. This study aims to analyze the fixed anatomical bony landmarks of the anterior skull base through coronal and reconstructed CT in the context of the Nepalese population and guide the surgeon to perform endoscopic sinus and skull base surgery safely. This Prospective study includes 70 Computerized Tomography scans of Paranasal sinuses. The different measurement from nasal floor to skull base was taken in coronal and reformatted sagittal CT scan. Mean, standard deviation, minimum and maximum values were analyzed using descriptive statistics. Student T-test was applied to compare between right and left side. This study includes 75 patients between 18 to 77 years. The measurement from nasal floor to the cribriform plate and ethmoidal roof in right and left side were, mean± SD (47± 4.1, 45.3±4.3, 47.9±5.1, and 49±8.5 mm) respectively. Mean Take off angle at the cribriform plate was 43.9 ±10.9°on right side and 43 ± 9.4° on the left side. The distance from the nasal spine to the skull base (mean ± SD) at nasofrontal recess, bulla ethmoidalis, and the junction of sphenoethmoid levels at right sides were 51.5 ± 4.7, 52.9 ± 4.1, and 61.2 ±4.7 little higher at left side. This study provides a detailed analysis of the anterior skull base in coronal and sagittal CT scans which helps to reduces complications.
... Then in 1910, Oskar Hirsh, an otolaryngologist, introduced a transseptal transsphenoidal approach to the pituitary gland, an operation which is still in use nowadays. 4 In 1992, Jankowski reported the first successful surgical cases using the endoscopic transsphenoidal approach to the hypophysis. This was the less traumatic route to the sella turcica, avoiding brain retraction, and also permitting good visualization, with lower rates of morbidity and mortality when compared to the transcranial route. ...
Background: Endoscopic surgery techniques had been advancing in this last two decades. Transsphenoidal approach endoscopic surgery to the skull base provides better visualization of the operation field compared to microscopic surgery, and also brought lower morbidity than other techniques. Purpose: To report a transsphenoidal endoscopic skull base surgery for craniopharyngioma resection. Case Report: A case of craniopharyngioma in a 47-year-old man. The tumor resection was performed with transsphenoidal endoscopic approach, in collaboration with a neurosurgeon. Clinical Question: Is transsphenoidal endoscopic skull base surgery approach, the appropriate surgical procedure for craniopharyngioma management? Review Method: Evidence based literature study of skull base surgery with transsphenoidal endoscopic approach in craniopharyngioma through database Cochrane library, Pubmed Medline, and hand searching. Result: Skull base surgery with transsphenoidal endoscopic approach was minimally invasive with maximally invasion compared to transcranial surgery, and also provided better view, and could reduce complication rate. Conclusion: Skull base surgery with transsphenoidal endoscopic approach offers more advantage in skull base lesion management compared to other techniques. Collaboration between neurosurgeon and otorhinolaryngologist using this technique could reduce complication and morbidity rate.
... Additionally, it provides a short working distance to large petrosal and petroclival lesions and their extensions to the subtemporal-infratemporal areas [31]. The posterior petrosal translabyrinthinetranscochlear approach offers a notable corridor when compared to other petrosal approaches, but it comes with the price of total hearing loss and a certain degree of facial nerve palsy related to the posterior transposition in the vast majority of cases with low rates of complete recovery [29,32,33]. Subsequently, several approaches have been reported to preserve hearing and facial nerve function. ...
The current literature regarding surgical treatment for tumors in the sphenopetroclival (SPC) region is merely scarce. Through a comprehensive literature review, we investigated the indications, outcomes, and complications of different surgical approaches to the SPC meningiomas. Given its complicated relationship between these slow-progression tumors and some critical neurovascular structures in the SPC region, surgical treatment of these tumors faces the challenge of achieving a maximal grade of resection, while preserving patient functionality. The development of new surgical techniques and approaches in recent years have permitted the advancement in the treatment of these tumors, with acceptable rates of morbidity and mortality. The choice of a surgical approach as a treatment for the lesion depends mainly on the type of tumor extension, surgeon’s preferences, and the displacement of neurovascular structures. Rather than focusing on one single strategy of treatment, the skull-base surgeon should tailor the approach based on the origin and features of the lesion; as well as the peculiarities of the surgical anatomy. This strategy aims to decrease morbidity and to optimize tumor resection and patient quality of life.
... Then in 1910, Oskar Hirsh, an otolaryngologist, introduced a transseptal transsphenoidal approach to the pituitary gland, an operation which is still in use nowadays. 4 In 1992, Jankowski reported the first successful surgical cases using the endoscopic transsphenoidal approach to the hypophysis. This was the less traumatic route to the sella turcica, avoiding brain retraction, and also permitting good visualization, with lower rates of morbidity and mortality when compared to the transcranial route. ...
Background: Endoscopic surgery techniques had been advancing in this last two decades. Transsphenoidal approach endoscopic surgery to the skull base provides better visualization of the operation field compared to microscopic surgery, and also brought lower morbidity than other techniques. Purpose: To report a transsphenoidal endoscopic skull base surgery for craniopharyngioma resection. Case Report: A case of craniopharyngioma in a 47-year-old man. The tumor resection was performed with transsphenoidal endoscopic approach, in collaboration with a neurosurgeon. Clinical Question: Is transsphenoidal endoscopic skull base surgery approach, the appropriate surgical procedure for craniopharyngioma management? Review Method: Evidence based literature study of skull base surgery with transsphenoidal endoscopic approach in craniopharyngioma through database Cochrane library, Pubmed Medline, and hand searching. Result: Skull base surgery with transsphenoidal endoscopic approach was minimally invasive with maximally invasion compared to transcranial surgery, and also provided better view, and could reduce complication rate. Conclusion: Skull base surgery with transsphenoidal endoscopic approach offers more advantage in skull base lesion management compared to other techniques. Collaboration between neurosurgeon and otorhinolaryngologist using this technique could reduce complication and morbidity rate. ABSTRAKLatar belakang: Teknik operasi endoskopi mengalami perkembangan pesat dalam dua dekade terakhir. Bedah basis kranii dengan pendekatan endoskopi transfenoid memberikan kualitas visualisasi lapang pandang operasi lebih baik dibanding menggunakan mikroskop, dan juga mengakibatkan morbiditas lebih rendah dibanding teknik lainnya. Tujuan: Melaporkan keberhasilan bedah basis kranii dengan pendekatan endoskopi transfenoid pada kraniofaringioma. Laporan kasus: Seorang laki-laki 47 tahun dengan diagnosis kraniofaringioma yang dilakukan tindakan reseksi tumor dengan pendekatan endoskopi transfenoid berkolaborasi dengan ahli bedah saraf. Pertanyaan Klinis: Apakah bedah basis kranii dengan pendekatan endoskopi transfenoid merupakan teknik operasi yang tepat untuk tatalaksana kraniofaringioma? Telaah literatur: Telaah literatur berbasis bukti mengenai bedah basis kranii dengan pendekatan endoskopi transfenoid pada kraniofaringioma melalui database Cochrane library, Pubmed Medline, dan pencarian manual. Hasil: Bedah basis kranii dengan pendekatan endoskopi transfenoid memberikan akses minimal dengan invasi maksimal, visualisasi lebih baik, dan dapat menurunkan angka komplikasi. Kesimpulan: Bedah basis kranii dengan pendekatan endoskopi transfenoid merupakan teknik operasi lesi basis kranii yang lebih unggul dibandingkan teknik lainnya. Kolaborasi antara ahli bedah saraf dan THT dapat mengurangi angka komplikasi dan morbiditas tindakan ini.
... On the other hand, the robotic system provides highdefinition three-dimensional view on surgeon's console that enables the surgeon to have a magnificent perception of depth in the surgical field. Second, endoscopic surgery of the skull base is ergonomically unfavorable and has some technical difficulties [3,30]. One problem is that bimanual surgery is only available when working with the 4 hands technique, which means two surgeons have to work in a narrow space from two nostrils, one holding the endoscope and the other the surgical instruments. ...
... The robotic system has three or four arms, one holding the endoscope, all of which are controlled by the surgeon from the console. The robotic instruments have seven degrees of freedom and 90 degrees of articulation that enables the surgeon to reach areas that are otherwise hard to access in a tremorfree manner [3,30]. Third concern regarding the EEA is the surgeon not being able to suture dural defects which would ensure impervious closure. ...
Czech novelist Karel Čapek introduced the word “robot” to the English language in his science fiction play Rossum’s Universal Robots (Rossumovi Univerzální Roboti) in 1920. Robotic systems in the field of medicine are remote performers that operate via the master-slave style. The only Food and Drug Administration (FDA)-approved surgical robotic system, the Da Vinci® (Intuitive Surgical International, CA), is designed to imitate the surgeons’ hand movements. The system consists of three major parts: the surgical console, the patient-side cart, and the vision cart. The surgical console is the remote part in which the surgeon operates seated by grasping the handpieces while viewing 3D images. The patient-side cart has three or four arms on which EndoWrist® instruments were installed that enable 7 degrees of motion performing surgeons’ hand commands. An endoscope is attached on one of these arms. The vision cart is equipped with a high-definition 3D endoscope and image-processing equipment. Although lagged behind the other surgical specialties, the use of robotics in otorhinolaryngology-head and neck surgery has recently gained a significant popularity. Studies by Hockstein, O’Malley, and Weinstein et al. revealed the usefulness of robotic surgery in the oropharynx, hypopharynx, and larynx. They pioneered the emergence of transoral robotic surgery (TORS), and after these leading studies, an FDA approval for TORS was gained for the benign diseases and T1 and T2 malignancies of head and neck in 2009. Recently, robot-assisted surgery is being intensively investigated and performed in all fields of otorhinolaryngology from thyroidectomy to cochlear implant insertion and from obstructive sleep apnea to skull base surgery and to other subspecialties.
... Extending the zonal dissection of the skull base beyond the sellar opening has been extensively described in the literature. 6,[9][10][11][12][13] Possible extensions that can be applied when addressing larger lesions of the skull base include transcribriform, transplanum, transtuberculum, and transclivus extensions. 14,15 These extensions of the surgical route depend on the size and firmness of the treated lesion: zonal dissection of the base of skull. ...
Mononostril Transseptal Transsphenoidal Resection of a Pituitary Macroadenoma:
Pituitary macroadenomas are the most frequent lesions encountered when performing endonasal endoscopic surgery. A systematic approach in resecting these lesions leads to a higher routine for the surgeon and therefore better results in the extent of resection. Described surgical corridors to the sphenoid sinus include the transseptal, transnasal, and transethmoidal approach. In the authors’ institution, the preferred approach is a transseptal transsphenoidal approach with removal of the superior and preservation of the middle turbinates. This technique was initially used with the assistance of a modified speculum.
Binostril Transseptal Transsphenoidal Approach for a Large Solid Pediatric Adamantinomatous Craniopharyngioma Involving the Third Ventricle:
Tailoring the nasal approach using both nostrils for the surgical resection of larger sellar lesions allows a broader range of maneuvers. The binostril approach provides more flexibility for the ENT surgeon in terms of positioning of the endoscope and allows a two-surgeon four-hand technique. The possibility for the neurosurgeon to bimanually dissect using microsurgical instruments are of particular importance when addressing suprasellar lesion like craniopharyngioma that, when compared with pituitary adenoma, tend to adhere and be in close relationship with critical neurovascular structures and might even extend into the third ventricle.
Expanded Endonasal Endoscopic Transplanum Transtuberculum Approach for a Tuberculum Sellae Meningioma:
Extending the zonal dissection of the skull base beyond the sellar opening has been extensively described in the literature. Possible extensions that can be applied when addressing larger lesions of the skull base include transcribriform, transplanum, transtuberculum, and transclivus extensions. These extensions of the surgical route depend on the size and firmness of the treated lesion: zonal dissection of the base of skull. In the modern era of endonasal endoscopic surgeries, suprasellar meningiomas have been more and more amenable for pure endoscopic endonasal resection. The proximity to critical surrounding neurovascular structures remains a challenging feature of these tumors. Many groups around the world report the extension of the classic midline corridor to the tuberculum sellae and planum sphenoidale. The correct indication and assessment of factors that predict non-successful or incomplete resection of skull base meningioma previous to surgery are of great importance. Transcranial approaches are well described and have to be considered when resection of these lesions is necessary.
... The surgery was performed using the 2-surgeon 4-hand technique. 22 The surgeons were standing on each side of the patient; the screen was positioned behind the patient's head along with the intraoperative neuronavigation. A 0 endoscope was used (Karl Storz Endoskope, Schaffhausen, Switzerland). ...
Background
Data on the endonasal endoscopic approach (EEA) to treat sellar/parasellar synchronous tumors remains sparse. The present work aims to describe a minimally-invasive approach with intraoperative magnetic resonance imaging (iMRI) to remove a large sellar/parasellar synchronous tumor, and presents a systematical literature review.
Methods
The preoperative MRI of a 54-year-old female patient revealed a sellar lesion (28x19x16mm), presumably a pituitary macroadenoma, and a second extra-axial lesion (22x36x20mm) expanding from the tuberculum sellae to the planum sphenoidale with encasement of the anterior communicating complex, presumably a meningioma. The authors used iMRI to assess the extent of the resection before reconstructing the large skull base defect. Furthermore, they systematically reviewed pertinent articles retrieved by a PubMed/EMBASE database search between 1961 and December 2018.
Results
Out of 63 patients with synchronous tumors reported in 43 publications, the authors found three patients in which the tumor was removed by EEA. In these three patients as well as the presented case, the resection of both lesions was successful, without major approach-related morbidity or mortality. More extensive removal of endonasal structures to gain an adequate tumor exposure was not necessary. The authors did not find any previous reports describing the benefits of iMRI in the presented setting.
Conclusions
In the rare case of a synchronous meningioma and pituitary adenoma of the sellar region, iMRI might be beneficial in confirming residual disease before skull base reconstruction, and therefore radiological follow-up.
