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o f t h e Ve n t r a l S k u l l
BaseEndoscopic
Tr a n s c r a n i a l Su r g e r y
Amol M. Bhatki, MDa, Ricardo L. Carrau, MDb,c,*,
Carl H. Snyderman, MDa,c, Daniel M. Prevedello, MDc,
Paul A. Gardner, MDc, Amin B. Kassam, MDa,c
KEYWORDS
Endoscopic Skull Base Surgery
Reconstruction Tumors
a
Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, 200
Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA
b
Department of Otolaryngology Head and Neck Surgery, Eye and Ear Institute, University of Pittsburgh
School of Medicine, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA
c
Department of Neurological Surgery, University of Pittsburgh School of Medicine, 200 Lothrop Street, Suite
500, Pittsburgh, PA 15213, USA
* Corresponding author. Department of Otolaryngology Head and Neck Surgery, Eye and Ear Institute,
University of Pittsburgh School of Medicine, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213.
E-mail address: carraurl@gmail.com (R.L. Carrau).
oralmaxsurgery.theclinics.com
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endoscope by providing a dynamic, xreal-time
view with continual adjustments to provide the best
view, appropriate magnification, and to guide
instruments and assist with dissection. A skilled
and experienced surgical duo working together is
a major advantage for intraoperative decisionmaking, delineation of complex or distorted
anatomy, and for the management of potentially
catastrophic vascular injuries.
A rod-lens endoscope (Karl Storz, Tuttlingen,
Germany), in itself, confers multiple advantages
that allow a minimal-access approach. It has
a narrow profile that is 4 mm in diameter, which
allows its introduction through small apertures.
This obviates extensive transfacial or transcranial
approaches (typically required for microscopic
visualization), with their resultant tissue disruption.
Furthermore, the lens of a rod-lens endoscope is
divergent and provides a panoramic view that
greatly exceeds its 4-mm diameter. By changing
the proximity of the scope to the operative field,
magnification is simple and precise, and with the
advent of high-definition camera systems, clarity
of the image is unparalleled. Rod-lens endoscopes
provide enhanced visualization, and the use of
angled lenses avoids the line-of-sight limitations
of the microscope. Although binocular 3-dimensional vision is lost, the surgeons brain quickly
adapts to working in 2-dimensional views by using
proprioceptive cues and surgical landmarks.
The sinonasal cavity provides an ideal corridor
for the surgical treatment of ventral cranial base
lesions (Fig. 1). Conventional (open) approaches
consist of facial or scalp incisions combined with
a craniotomy and/or maxillofacial osteotomies.
Postoperative pain after conventional approaches
is significant and convalescence may take weeks.
Surgical scars and complications, such as wound
infection, bone malunion, and loss of cranio-orbital
bone grafts, can result in substantial facial disfigurement. In addition, transcranial approaches often
mandate brain retraction and manipulation, which
may result in cognitive or memory dysfunction.
Alternatively, the use of an EEA provides a direct
caudal approach to the ventral skull base obviating
brain manipulation. Furthermore, facial incisions,
osteotomies, and bone grafts are unnecessary,
greatly decreasing postoperative pain and eliminating facial scarring and disfigurement. Of greatest benefit, however, is that the EEA provides
unhindered access to the midline corridor that is
flanked by cranial nerves and internal carotid
arteries.7,8 Endonasal access thus obviates cranial
nerve manipulation that beleaguers conventional
lateral approaches.
Paramount to efficient and successful skull base
surgery is choosing the best corridor or combination
Fig. 2. (A) T1-weighted, contrast-enhanced, coronal magnetic resonance image (MRI) of a patient with a right
anterior clinoid meningioma (T). The white arrows indicate the location of both optic nerves as they course
lateral to the sphenoid (Sp) sinus. The right optic nerve, which lies medial and inferior to the tumor, would
obstruct endonasal (transsphenoidal) access. Because the nerve cannot be mobilized, this case is best done
through an open, pterional craniotomy. (B) T1-weighted, contrast-enhanced, coronal MRI of a patient with
an olfactory groove meningioma tumor (T). White arrows locate the optic nerves lateral to the tumor. Because
the optic nerves are not interposed between the skull base and the lesion, this tumor is amenable to EEA.
PREOPERATIVE EVALUATION
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parameningeal involvement require a lumbar
spinal tap for cytology and a spine MRI to rule
out drop metastasis or carcinomatosis.
INTRAOPERATIVE STRATEGIES
Fig. 5. (A) Sagittal CTA of a patient with a large olfactory groove meningioma tumor (T). The A2 segments of
both anterior cerebral arteries (arrowheads) have been displaced superiorly and directly juxtapose the superior
aspect of the tumor, making the tumor-brain interface dissection technically difficult. The parasellar internal
carotid artery (C), sphenoid sinus (Sp) and vertebral artery (arrow) are also seen. (B) A sagittal CTA of another
patient with a meningioma (T). A cuff of brain parenchyma (arrowhead) intercedes between the tumor and
the A2 arteries (arrow). Dissection of the brain tumor interface is technically easier in such cases.
Fig. 6. Intraoperative snapshot of the image-guidance system for a patient with a right petroclival meningioma
(white arrowhead and asterisk). The tumor emanates from the jugular tubercle (JT) just above the hypoglossal
canals (black arrows). After the vidian canal (black arrowhead) was drilled away, the internal carotid artery
(ICA) was mobilized to obtain access to the tumor.
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[Johnson and Johnson], Somerville, NJ, USA), or
Syvek (Marine Polymer, Boston, MA, USA).
In the case of high-flow arterial bleeding, direct
application of bipolar cauterization or hemostatic
or aneurysms clips is paramount. Although
packing may provide temporary hemostasis, the
potential for delayed intracranial bleeding
mandates definitive control. Collaborative experience with the 2-surgeon approach is requisite for
maintaining adequate visualization in a bloody
field. Similarly, a bimanual approach facilitates
suctioning with concomitant cautery (Fig. 7). On
occasion, in the face of significant operative blood
loss, tumor resections may be staged to allow
hemodynamic recovery.
SURGICAL APPROACHES
The concept of surgical corridors typical of open
skull base surgery can also be adopted for endoscopic skull base surgery; therefore, the endoscopic approaches to the ventral skull base have
been defined by a series of surgical modules.
These modules define the sinonasal exposure,
the location and extent of skull base osteotomies,
and the anticipated extracranial and intracranial
anatomy. Furthermore, these modules can be
combined to control multiple areas of the skull
base and, segmentally, address a large, complex
tumor as necessary. These modules have been
categorized based on their relationship to the
internal carotid artery (ICA); the sagittal plane
modules define corridors medial to the ICA,
whereas paramedian corridors lateral to the ICA
are addressed by coronal plane modules.
Fig. 7. (A) Intraoperative photograph of a suprasellar tumor (T) dissection. A small vessel feeding the tumor is
present (arrowhead). The A2 segment of the anterior cerebral artery (white arrow) is adjacent to the tumor.
(B) Bipolar microcautery is meticulously applied to the vessel before transection.
Fig. 8. (A) T1-weighted coronal MRI scan postcontrast demonstrates a large olfactory groove meningioma (T)
with the A2 segments of the anterior cerebral arteries (arrows) flanking the tumor. (B) Postresection MRI, 3
months postoperative, shows complete tumor excision. The sphenoid is obliterated with fat and the skull base
was reconstructed with a nasoseptal flap (asterisk).
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Fig. 9. Enclosed within the dotted lines is a right petroclival chondrosarcoma seen in the CTA. A transclival
(C) module was used to approach and resect this
tumor. The internal carotid artery (asterisk), vidian
canal (white arrow), and basilar artery (arrowhead)
are shown in relation to the tumor. Note the vidian
canals relationship to the anterior portion of the
petrous ICA (asterisk).
RECONSTRUCTION
As endoscopic skull base resections have
continued to increase in complexity, new challenges have been presented for the reconstruction
of these defects. Indeed, the continued evolution
of the EEA to successfully and safely address
larger and more intricate lesions has been
commensurate with the development and growing
experience with vascularized reconstructions.
All skull base reconstructions strive to recreate
a separation of the cranial cavity from the sinonasal cavity to prevent CSF fluid leakage, pneumocephalus, and intracranial infection. Small
skull base defects and CSF fistulas can be reconstructed with various free-grafting techniques, resulting in a success rate greater than 95%.25,26
However, for large dural defects, free grafts are
associated with unacceptably high rates of postoperative CSF leakage typical after an EEA. The
lack of supporting structures and high flow of
CSF in cisterns and ventricles pose further challenges to the reliability of reconstruction.
Initial reconstructions strategies consisted of
suturing of allografts, buttressing the dural repair
with free fat grafts, and supporting the reconstruction
Fig. 11. 20 year-old patient with a right intraconal optic nerve glioma. (A) Coronal contrasted, T1-weighted MRI
showing the heterogeneously-enhancing tumor (T). Note how the medial rectus (white arrow) and superior oblique (black arrow) obstruct the transorbital corridor from the ethmoids (asterisk). These muscles must be splayed
by gentle traction to accommodate endoscopic endonasal instrumentation. The patients left side provides
comparative normal ethmoid and orbital anatomy. (B) Axial T1-weighted MRI showing the tumor (T) displacing
the medial rectus (white arrow) medially. Septations within the sphenoid (S) and ethmoid (E) sinuses on the
affected side must be removed to provide adequate exposure.
Fig. 12. Axial T1-weighted, contrast-enhanced, MR of a patient with a large JNA. (A) The tumor (T) fills the right
nasal cavity, nasopharynx and extends into the infratemporal fossa (arrowheads) displacing the medial pterygoid
and temporalis muscles (asterisk) laterally. (B) Adjacent section shows the tumor (T) expanding the vidian canal
(arrow) proximally toward the petrous portion of the carotid artery (white arrowhead).
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Fig. 13. Intraoperative photograph after a left pterygopalatine osteosarcoma resection. The sella (S) and
clival recess (CR) are seen medially. Again, the vidian
nerve (arrowhead) is seen just anterior to the paraclival carotid artery (C). The lingular process of the sphenoid bone has been removed (asterisk) exposing the
bony canal of the petrous carotid artery. Cranial nerve
V2 is seen emanating from foramen rotundum and
projecting anterolaterally and V3 is found just distal
to foramen rotundum and travels inferolaterally.
Fig. 14. Intraoperative photograph of anterior craniofacial defect (from Fig. 4) with complete reconstruction by the NSF in an onlay fashion. The sphenoid
(Sp) is seen posteriorly.
NSF may be necessary to provide adequate reconstruction. The reach of the flap is maximized when it
is on a planar surface instead of following the
curves of the sinuses and skull base. Obliteration
of a sphenoid or clival defect with a fat graft will
allow the NSF to reliably reach the posterior table
of the frontal sinus, if necessary.
If the NSF is not available because of tumor
invasion, septal perforation, or prior sacrifice of
the pedicle, adjuvant vascularized flaps may be
used to provide a reliable reconstruction. Local endonasal pedicled flaps include inferior turbinate
and middle turbinate mucoperiosteal flaps.31,32
Both flaps are pedicled posteriorly on respective
branches of the SPA. Although both flaps provide
a more limited surface area than the NSF, they
may be sufficient for small defects of the planum
sphenoidale and sella (middle turbinate flap) or
the clivus (inferior turbinate flap).
For large skull base defects where the NSF is
unavailable, regional axial flaps may be used for
reconstruction: the endoscopic pericranial flap
and the transpterygoid temporoparietal fascia
flap.33,34 Although both flaps require scalp incisions, they can be transposed endonasally and
placed onto the skull base defect without the use
of a craniotomy. For the endoscopic pericranial
flap, the loose areolar tissue and pericranium of
the scalp are harvested, much the same as for
open cranial base surgery. The flap is pedicled
on the supratrochlear and supraorbital vessels
and transposed endonasally via a narrow glabellar
osteotomy, obviating craniotomy.33 A Draf III
endoscopic frontal sinusotomy, requisite for this
procedure, accommodates the pedicle as it is
transposed. Tissue from this flap is ideal for large
defects secondary to transcribriform, transplanum, or transsellar modules.
CONTROVERSIES
One of the major controversies surrounding endoscopic skull base surgery is the oncological validity of endoscopic techniques. Critics of the EEA
cite that en bloc resection is essential for surgical
tumor control.35 However, numerous examples in
current medical practice refute this claim. Endoscopic removal of inverting papilloma of the sinonasal cavity has shown to have equivalent or
even superior results to conventional en bloc
partial maxillectomy.36 Tumor debulking, in this
case, provides for better exposure and delineation
of normal and abnormal anatomy. The stalk or
base of the tumor can be easily identified and resected totally, providing an equally complete extirpation.
Mohs
micrographic
surgery
for
dermatologic neoplasms and transoral supraglottic laryngectomy for laryngeal neoplasms have
similarly shown that en bloc resection is not
needed to achieve adequate and appropriate
tumor control. In reality, given the proximity to
neural and vascular structures and friability of
tumors, en bloc resection of skull base malignancies is often not possible even with a traditional
open approach.
However, EEA techniques must conform to oncological principles. It is of utmost importance to
achieve clear surgical margins, as confirmed by intraoperative analysis. To address a sinonasal tumor
SUMMARY
The continued progression of the EEA to cranial
base lesions has been spurred by advances in
instrument and imaging technology, growth in
anatomic knowledge and surgical experience,
and innovations in reconstructive techniques.
Currently, a wide variety of malignant and benign
lesions may be treated via the endonasal corridor
without using facial incisions, craniotomy, or brain
retraction. Understanding the complex, 3-dimensional anatomy is essential for success and safety.
Although the endonasal route provides a less intrusive corridor, the surgical principles of resection,
especially for malignancies, are not violated; tumor
resections and resultant skull base defects mirror
those of traditional open approaches.
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