Endoscopic Pituitary Surgery

A Computed Tomography (CT)-Based Observational Study of Anatomical Variations in the Sphenoid Sinus: Implications for Surgical Planning and Patient Outcomes

INTRODUCTION

 The sphenoid sinus (SS), a paired paranasal sinus located within the sphenoid bone, is crucial in various physiological and pathological processes. Its anatomical variations are of significant interest in clinical practice, particularly in otolaryngology, neurosurgery, and radiology. This study aims to determine the anatomical variations of the SS and related structures using computed tomography (CT).

MATERIALS AND METHODS

An observational study was conducted at a tertiary care center. The study included 300 patients aged 7-70 who underwent CT brain scans. Exclusions included prior sinonasal surgeries, tumors, nasal polyposis, recurrent pituitary lesions, head trauma, and past orbital or cranial surgeries. Three-dimensional reconstructions assessed SS dimensions, pneumatization types, and variations in the internal carotid artery and optic nerve.

RESULTS

A study on the types of SSs revealed that the reseller type is the most common, accounting for 45% of cases (135 instances). The sellar type accounts for 36% (110 instances), while the conchal type is the least common, observed in 18.33% of cases (55 instances). A significant association between the SS type and variations between neurovascular structures was seen, which was confirmed using chi-square tests. There was a statistically significant relationship between carotid artery variations and SS, with the normal course being predominant at 200 individuals (73.33%). Approximately 40 cases (13.33%) present with dehiscence through the sinus, while 30 individuals (10%) show close proximity. Other, less common variations are observed in 10 patients (3.33%). Optic nerve variations displayed distinct frequencies, with the normal course prevailing in 250 cases (83.33%). Approximately 30 cases (10%) exhibit close proximity to surrounding structures, while 15 cases (5%) present with dehiscence through the sinus. Other less common optic nerve variations are observed in five patients (1.67%).

CONCLUSION

 Comprehensive knowledge of SS anatomy through CT scans is essential for enhancing surgical outcomes and ensuring patient safety.

A Study of Anatomical Variations of Sphenoid Sinus on CT PNS: Our Experience

Sphenoid sinus anatomical variations are very common, its prior knowledge is very essential while doing skull base surgery to avoid catastrophic complications which might be due to damage of surrounding neurovascular structures. This retrospective observational study was done to examine the different anatomical variations of sphenoid sinus on CT PNS which was conducted in KMCH, Katihar from May 2019 to April 2020 involving 60 cases above 15 years of age who had undergone CT PNS. Sellar type of pneumatization was seen in 66.7%, pterygoid process pneumatization was seen in 25%. Single septation was present in 43.3%, septum attached to optic nerve was seen in 33.3%, onodi cell was seen in 36.7%, anterior clinoid process pneumatization was seen in 13.3% of cases. By this study we came to a conclusion that preoperative assessment of sphenoid sinus anatomy and its variations is mandatory to avoid surrounding neurovascular structure damage and CSF leak.

Endoscopic Endo-nasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Prospective Study

The surgical approach for hypophysectomy has undergone sweeping revolution in the past three decades. With the advent of endoscopes, better instrumentation, better illumination and viewing cameras, endoscopic endo-nasal trans-sphenoidal approach to sella has now largely become the norm. The aim of this study is to present our experience, analysing the surgical outcomes of this approach in patients with pituitary adenoma, pertaining to entirety of tumor removal, alleviation of symptoms and rate of complications. This prospective  study was conducted at our tertiary health care  centre from June 2012 to June 2015. A total of 14 patients, meeting the inclusion criteria, underwent endoscopic trans-sphenoidal hypophysectomy for pituitary adenoma. Age of presentation ranged from 19 to 73 years (mean 43.6 years). 9 patients were female and 5 were male. The most common presenting symptom was headache, followed by visual disturbances. Amongst those with hormonal imbalance, most common were prolactinomas and growth hormone secreting adenomas. Preoperative MRI brain showed macroadenomas in all 14 patients. 7 (50%) patients had suprasellar extension, while 5 (36%) patients had intracavernous extension too. CT paranasal sinuses provided the roadmap for surgery by identifying anatomical variations. Alleviation of headache occurred in all cases. Normalization of altered hormonal profile was seen in all cases. 83.3% of our patients with visual field defects on perimetry showed improvement post-surgery. Recidivism was directly related to the size and extent of adenoma. Transient diabetes insipidus was seen in 4 (28%) cases. Persistent diabetes insipidus occurred in 1 (7%) patient. CSF leak was seen in 2 (14%) patients, 1 (7%) patient developed postoperative meningitis. Most common nasal complication was excessive crusting. There was no incidence of any vascular complications, focal neurological deficit or hypopituitarism in our study. The pure endoscopic approach is a safe, efficacious, and minimally invasive technique for the removal of pituitary adenomas. The results have been encouraging in our prospective study. However, the importance of learning curve in endoscopic skull base surgery and use of a multi-disciplinary collaboration cannot be overemphasized.

Assessment of post-operative healing following endoscopic, transnasal, transsphenoidal pituitary surgery without formal sellar grafting

INTRODUCTION

Multiple options exist for sellar reconstruction after endoscopic transnasal, transsphenoidal surgery (TSS) including free mucosa, fat, bone and synthetic materials. The objective of this study was to assess healing and mucosalization of the sellar face following TSS without formal sellar grafting or reconstruction.

METHODS

Single institution retrospective chart review was conducted for patients undergoing TSS without intraoperative CSF leaks between January 2014 and March 2017 at Rush University Medical Center. No formal sellar reconstruction was performed for the entire patient group. Follow-up endoscopic data and clinical notes were coded for time to mucosalization of the sella as well as degree of abnormal mucosal healing, epistaxis, crusting and scarring.

RESULTS

83 patients were included in this study. Mean time to mucosalization was 119 days (range, 17 to 402 days). Incidence of abnormal mucosal healing, epistaxis, crusting and scarring increased from the first to the second postoperative visit but trended down by the third visit. Nasal crusting was the most common finding, followed by abnormal mucosal healing. Chi square analysis showed smoking to be associated with prolonged time to full mucosalization of the sella. Two patients (2.4%) had post-operative CSF leaks requiring lumbar drain placement.

CONCLUSION

Adequate sellar healing is achievable in all cases without formal grafting or reconstruction after TSS. Great care must be exercised given the small inherent risk of unmasking a subclinical intraoperative CSF leak. Patients should be followed closely endoscopically during the first four months after TSS to minimize the impact of crusting.

Is Coincidental Rhinosinusitis a Predisposing Factor for Postoperative Central Nervous System Infection After Endoscopic Endonasal Transsphenoidal Surgery?

BACKGROUND

To investigate the effect of rhinosinusitis in patients who undergo surgery via the endoscopic endonasal transsphenoidal approach (EETSA).

METHODS

The authors retrospectively reviewed the medical records of patients who underwent surgery via the EETSA between February 2009 and November 2016. In total, 505 patients were included in the study. Preoperative paranasal sinus computed tomography, sellar magnetic resonance imaging, and nasal endoscopy were performed for all the patients.

RESULTS

Fifteen patients without sphenoid sinusitis underwent surgery with the concomitant transsphenoidal approach and functional endoscopic sinus surgery, and showed no central nervous system (CNS) complication. During surgery via the EETSA, the presence of rhinosinusitis did not significantly affect the incidence of postoperative CNS infection (P = 0.051), except for sphenoid sinusitis (P = 0.003). Conversely, the incidence of postoperative CNS infection was not related significantly to the Lund-Mackay score or tumor size. The risk of CNS infection was 12.151-fold higher in patients with sphenoid sinusitis (95% confidence interval, 3.153-46.827; P ≤ 0.001).

CONCLUSION

Surgery via the EETSA and functional endoscopic sinus surgery can be safely performed together in most patients with rhinosinusitis. However, sphenoid sinus infection appears to be a predisposing factor for postoperative CNS infection. Therefore, a separate surgical procedure for sphenoid lesions should be considered in these patients before the use of the EETSA.

Evolution of sinonasal symptoms and mucosal healing after minimally invasive pituitary surgery

BACKGROUND

Minimally invasive pituitary surgery (MIPS) via endoscopy has become widely accepted as the surgical paradigm of choice for pituitary pathology. The objective of the current study was to analyze the evolution of symptom scores and mucosal healing after MIPS.

METHODS

The 22-item Sino-Nasal Outcome Test (SNOT-22) scores and objective endoscopic data of 52 patients were reviewed in a longitudinal manner. Scaled averages of the SNOT-22 and endoscopic scores from different time points were compared with baseline scores by using nonparametric testing. The time to baseline for endoscopic examinations was also analyzed by using Kaplan-Meier curves.

RESULTS

The rhinologic symptoms subdomain of the SNOT-22 scores showed statistically significant worsening between baseline and 2 weeks after surgery (p = 0.03). Follow-up SNOT-22 scores after 2 weeks showed no significant differences compared with baseline scores, with an overall trend toward improvement in patient symptoms during the subsequent period. Similar analysis for the endoscopic data illustrated statistically significant differences from the baseline scores up to 16 weeks after surgery. The overall trend showed a worsened endoscopic examination, initially with a spike at ∼8 to 10 weeks (p = 0.03) and with a subsequent return to baseline. The Kaplan-Meier estimate curve demonstrated a median time to return to baseline endoscopy at 18.9 weeks (95% confidence interval, 14.9-38.3 weeks).

CONCLUSION

The longitudinal data exhibited subjective improvement of patient outcomes based on SNOT-22 scores within 2-4 weeks after MIPS. However, the objective endoscopic data revealed a lag in improvement of the examination, typically at 16-20 weeks, which underscores ongoing careful endoscopic assessment and management to ensure proper mucosal healing beyond just subjective symptoms as the gauge to postoperative recovery.

Is there a relationship between sphenoid sinus types, septation and symmetry; and septal deviation?

In the present study, we investigated whether there is a relationship between sphenoid sinus (SS) types, septation (lobulation) and symmetry; and septal deviation (SD) by multidetector computed tomography (MDCT). Paranasal MDCT images of 202 subjects (131 males, 71 females), between 10- and 88-year-old, were included into the study. SS type (conchal, presellar or sellar), SS symmetry, SS septation (lobulation) and SD were evaluated by MDCT images. In the present study, in both males (83.2 %) and females (85.9 %); and in all age groups (80.4-85.7 %), sellar type sphenoid sinus were more detected. Conchal type was detected in two cases of the males (1.5 %) and none of the females. SS was detected mainly as multi-septated (multi-lobulated) (51.9 % in males and 56.3 % in females; in all age groups as 51.0-56.8 %; and both SD (+) and SD (-) groups as 51.2-56.8 %). In subjects with SD, asymmetric SS was detected in 80.2 %. Whereas in SD (-) subjects, asymmetric SS was detected in 50.6 %. Sellar type SS pneumatization is the most detected type in our cases. Presence of SD was related to the higher SS asymmetry values. In SD (-) subjects, SS was detected as symmetric. Nasal septal deformities such as SD may influence the development of the SS pneumatization and asymmetric septation. For well anatomic orientation of the surgeons, good anatomy knowledge and preoperative detailed examination of the CT scans are very important.

Surgical Measurement of the Sphenoid Sinus on Sagittal Reformatted CT in the Turkish Population

OBJECTIVE

The objectives of this study were to determine sinus measurements specific for the Turkish population using CT sagittal thin-slice reconstruction images and to clarify the three-dimensional anatomical features of the sphenoid sinus, along with its surrounding structures, that are relevant to performing an endoscopic sphenoidotomy.

MATERIALS AND METHODS

Images of 300 patients (165 female, 135 male) were studied. The research was conducted on the axial plane with a 1 mm slice thickness and a 0.6 mm slice interval, and sagittal reconstruction was performed with a 0.4 mm slice interval. Measurements of the sinus were obtained, and the presence of Onodi cells was researched.

RESULTS

Line 1 was found to be significantly shorter in the Turkish patients of this study compared to studies of other populations. Lines 4 and 6 were found to be longer on the left side (Line 4 right: 18.8±3.6 mm, left: 19.3±3.4 mm, p=0.027; Line 6 right: 24.1±6.8 mm, left: 24.3±6.8 mm, p=0.008). Lines 2, 3, 4 and 6 were longer in men than in women (p<0.05).

CONCLUSION

In the Turkish population, Line 1 is shorter, so the risk of skull base perforation is greater. Lines 4 and 6 are longer on the left side; thus, choosing the left ostium in sinus dilation is safer. Because of sex differences regarding Lines 2, 3, 4 and 6, sex should be considered in sphenoid sinus procedures.

Endoscopic transnasal approach for removing pituitary tumors

To describe a series of 129 consecutive patients submitted to the resection of pituitary tumors using the endoscopic transsphenoidal approach in a public medical center.

METHOD

Retrospective analysis based on the records of patients submitted to the resection of a pituitary tumor through the endoscopic transsphenoidal approach between 2004 and 2009.

RESULTS

One hundred and twenty-nine records were analyzed. The tumor was non-secreting in 96 (74.42%) and secreting in 33 patients (22.58%). Out of the secretory tumors, the most prevalent was the growth hormone producer (7.65%), followed by the prolactinoma, (6.98%). Eleven patients developed cerebral spinal fluid (CSF) fistulas, and four of them developed meningitis. One patient died due to intracerebral hemorrhage in the postoperative period.

CONCLUSION

The endoscopic transsphenoidal approach to sellar tumors proved to be safe when the majority of the tumors were non-secreting. The most frequent complication was CSF. This technique can be done even in a public hospital with financial limits, since the health professionals are integrated.

Feasibility of piezoelectric endoscopic transsphenoidal craniotomy: a cadaveric study

Objective. Endoscopic transsphenoidal approach has become the gold standard for surgical treatment of treating pituitary adenomas or other lesions in that area. Opening of bony skull base has been performed with burrs, chisels, and hammers or standard instruments like punches and circular top knives. The creation of primary bone flaps—as in external craniotomies—is difficult.The piezoelectric osteotomes used in the present study allows creating a bone flap for endoscopic transnasal approaches in certain areas. The aim of this study was to prove the feasibility of piezoelectric endoscopic transnasal craniotomies. Study Design. Cadaveric study. Methods. On cadaveric specimens (N = 5), a piezoelectric system with specially designed hardware for endonasal application was applied and endoscopic transsphenoidal craniotomies at the sellar floor, tuberculum sellae, and planum sphenoidale were performed up to a size of 3–5 cm². Results. Bone flaps could be created without fracturing with the piezoosteotome and could be reimplanted. Endoscopic handling was unproblematic and time required was not exceeding standard procedures. Conclusion. In a cadaveric model, the piezoelectric endoscopic transsphenoidal craniotomy (PETC) is technically feasible. This technique allows the surgeon to create a bone flap in endoscopic transnasal approaches similar to existing standard transcranial craniotomies. Future trials will focus on skull base reconstruction using this bone flap.

Endoscopic Endonasal Transsphenoidal Resection for Pituitary Apoplexy during the Third Trimester of Pregnancy

Pituitary apoplexy is an uncommon phenomenon typically characterized by vascular insufficiency or acute hemorrhage into a pituitary adenoma. The overall incidence of pituitary apoplexy ranges between 1 and 25% of all pituitary adenomas. With the widespread use of MRI technology, the diagnosis of asymptomatic intratumoral hemorrhage is closer to 10%. The authors report a case of a 27-year-old female in her 36th week of pregnancy who presented with severe onset headache and acute left-sided vision loss. MRI of the brain revealed a large hemorrhagic mass occupying the sella turcica. The patient underwent an emergent endoscopic endonasal transsphenoidal resection for pituitary apoplexy. Postoperatively, the patient's neurologic deficit resolved. Minimally invasive endoscopic endonasal transsphenoidal resection of pituitary apoplexy can be safely utilized in third trimester pregnant women presenting with acute severe neurologic deficits.

Sinonasal quality of life outcomes after minimally invasive resection of sinonasal and skull-base tumors

BACKGROUND

Minimally invasive endoscopic resection (MIER) has emerged as the standard for surgical management of benign and malignant sinonasal and skull-base neoplasms. The objective of the present study was to assess sinonasal quality of life (QOL) and to analyze factors that impact symptomatology after surgery.

METHODS

This single-institution observational cohort study was performed on 94 patients over a 3-year period.

RESULTS

The mean age was 55.2 years, with male:female ratio of 1.5:1. Benign and malignant tumors were observed in 48% and 52% of patients, respectively. The cohort's mean preoperative 20-item Sino-Nasal Outcomes Test score (SNOT-20) was 1.27, decreasing to 0.91 (p = 0.002) at 6 months postoperatively. Patients with benign neoplasms had a lower mean preoperative SNOT-20 score of 1.11 that decreased to 0.58 (p = 0.002), whereas patients with malignant tumors had a higher mean preoperative SNOT-20 score of 1.27, decreasing to 1.03 (p = 0.134) at 6 months postoperatively. The SNOT-20 scores for females improved 0.53 (p = 0.002) compared to 0.23 (p = 0.154) for males at 6 months. Statistically significant sinonasal QOL improvement was noted in nonsmokers (0.62, p = 0.0006), patients with no prior radiation or chemotherapy (0.59, p = 0.0029), and patients with no prior surgery (0.51, p = 0.0012). Multiple variable regression analysis demonstrated that the 2 strongest predictors for lack of SNOT-20 improvement were previous history of smoking (p < 0.05) and prior radiation and/or chemotherapy (p < 0.01) (R(2) = 0.24).

CONCLUSION

MIER results in overall improvement in SNOT-20 scores, with greater change being noted in females and in patients with benign tumors. Prior smoking and chemoradiation strongly predict decreased improvement in sinonasal QOL after surgery.

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Anatomical landmarks for locating the sphenoid ostium during endoscopic endonasal approach: a cadaveric study

PURPOSE

The sphenoid ostium (SO) provides a natural portal for entering the sphenoid sinus and beyond up to the skull base. It is not always easy to locate the ostium during the endoscopic approach. The present study was designed to establish readily identifiable anatomical landmarks for locating the sphenoid ostium.

METHODS

Cadaveric dissection was performed in 30 hemisections of head and neck and various measurements were taken from fixed anatomical landmarks in the nasal cavity to the sphenoid ostium. The size, shape and position of sphenoid ostium were determined in relation to the anterior wall of the sphenoid sinus and the superior turbinate.

RESULTS

The mean distance from the supero-lateral angle of the posterior choana to the SO was found to be 21.21 ± 6.02 mm. The mean distance of the SO from the midline was 4.85 ± 2.89 mm. In all the specimens, the SO was situated within 1 cm of the midline. The mean distance between the inferior end of the SO and the postero-inferior edge of the superior turbinate was 8.03 ± 3.52 mm. The SO was present on an average distance of 55.1 ± 3.54 mm from the limen nasi. In 93.3 % of the specimens, the SO was situated between 5 and 6 cm of the inferior end of the limen nasi. The angle between the anterior nasal spine and the SO was found to be remarkably constant. In 93.3 % of the specimens, it was from 25° to 30°.

CONCLUSIONS

The sphenoid ostium could be localized medial to the superior turbinate between 1.5 and 3 cm above the supero-lateral angle of the posterior choana, within 1 cm of the midline and within 1 cm of the postero-inferior edge of the superior turbinate.

Clinical implications of rhinosinusitis detected by preoperative computed tomography for endoscopic endonasal transsphenoidal pituitary surgery

CONCLUSIONS

Rhinosinusitis detected by preoperative osteomeatal unit computed tomography (OMU CT) may not increase the incidence of postoperative central nervous system (CNS) infections.

OBJECTIVES

To evaluate the safety of endoscopic endonasal transsphenoidal pituitary surgery in patients who had rhinosinusitis detected by preoperative OMU CT.

METHODS

A total of 107 patients who underwent endoscopic endonasal transsphenoidal pituitary surgery were enrolled. The presence of rhinosinusitis and the location of involved sinuses were assessed by preoperative OMU CT. The extent of pituitary tumors was assessed by preoperative sellar MRI. The occurrence of intraoperative cerebrospinal fluid (CSF) leakage and postoperative central nervous system (CNS) complications were analyzed using the medical records. The correlations between these variables and postoperative CNS complications were examined.

RESULTS

After pituitary surgery, postoperative CNS complications occurred in four patients (3.7%). Twenty-eight patients (26.2%) had findings of rhinosinusitis on preoperative OMU CT. Of the 28 patients, 8 had rhinosinusitis in the anterior sinuses and 20 in the posterior sinuses. Intraoperative CSF leakage occurred in eight patients (7.5%). The occurrence of intraoperative CSF leakage showed a significant correlation with the incidence of postoperative CNS complications (p = 0.003) but not with the presence of rhinosinusitis (p = 0.134). Although not statistically significant, patients with rhinosinusitis in the posterior ethmoidal and/or sphenoidal sinuses tended to have higher incidences of postoperative CNS complications (p = 0.057).

Full Endoscopic Transsphenoidal Surgery for Pituitary Adenoma-emphasized on Surgical Skill of Otolaryngologist

The purpose is to summarize the experience in full endoscopic transsphenoidal resection of pituitary adenoma in 28 patients by rhinologist, and introduce the surgical skill of otolaryngologist, especially skills and cautions when operating inside nose. We removed pituitary adenoma in 28 patients via entirely endoscopic transsphenoidal approach with the help of special-designed instruments; we performed the procedure bloodlessly within limited time. The skill emphasized bilateral nostrils and four hands technique which was as delicate as possible not to scratch nasal mucosa or injure nasal frame. The special instruments included curette with suction, monopolar electrotome and bipolar coagulation forceps with suction, powered surgical equipments (Diamond Bur, Irrigation Tubing for Blades and Burs for nasal endoscopic surgery). Among 28 patients, there were 16 total resections, 8 subtotal resections, 3 partial resections, and 1 only biopsy due to excessive bleeding and hard nature. Of 19 patients with preoperative visual impairment, 12 patients had postoperative improvement in visual acuity and visual field. All the procedures were finished within 60 to 90 min. Complications seldom occurred except transient diabetes insipidus, especially no nasal-related signs or complications but 1 had epistaxis. The full endoscopic transsphenoidal surgery is a promising approach for pituitary adenoma resection. Multidisciplinary collaboration will lead to optimal cure for the patients. New technique and special-designed instruments can facilitate greatly this procedure.

Optimum height from the roof of the choana for seeking the sphenoid ostium

OBJECTIVE

The purpose of this study was to investigate the optimum height that the sphenoid sinus ostium can be probed safely from the roof of choana in a large group of patients.

METHODS

The study was performed retrospectively. The 200 sphenoid ostia of the 100 patients whose thin-section computed tomography (CT) including the sphenoid sinus region, made for various reasons, were included in the study. The height of the sphenoid ostium and the skull base from the choana roof were measured on sagittal images of CT. Also, by calculating the ratio of first measurement to the second one, the location of the sphenoid ostium at the anterior wall of sphenoid sinus was determined proportionally.

RESULTS

The mean height of the sphenoid ostium from the choana roof was 10.9 (SD, 2.3) mm (range, 5.7-21.5 mm), and the mean height of skull base along the anterior wall of sphenoid sinus from the choana roof was 21.3 (SD, 3.2) mm (range, 13.3-30.6 mm). The ratio of the first measurement to the second measurement was 0.5 (SD, 0.08) (range, 0.29-0.77).

CONCLUSIONS

In conclusion, under endoscopic view, the sphenoid sinus ostium can be safely probed between 13.3 mm (the minimum skull base height) and 5.7 mm (the minimum sphenoid sinus ostium height) distance upward from the choana, but determining the height of the sphenoid sinus ostium preoperatively on CTs for each patient separately will increase the chance of success in probing the sphenoid sinus.

Evolution of sinonasal symptoms following endoscopic anterior skull base surgery

To assess the severity and evolution of sinonasal symptoms in patients following endoscopic anterior skull base surgery to define the typical postoperative course.

DESIGN

Cross sectional study. Participants include 69 patients who underwent endoscopic skull base surgery by a dual surgeon team (otolaryngologist and neurosurgeon) from January 2008 to August 2009.

MAIN OUTCOME MEASURES

Sinonasal Outcomes Test (SNOT)-20 survey scores at preoperative and at three postoperative time points. An ordinal logistic regression model was used to analyze the data, summarizing the relationship between the outcome (SNOT score) and the predictor (time point) using an odds ratio. Scores for the symptoms of need to blow nose, sneezing, runny nose, postnasal discharge, thick nasal discharge, ear fullness, and facial pain showed significant worsening at the early postoperative time point. These symptoms showed significant improvement over time; however, scores for post nasal discharge remained high at the late time period compared with baseline. All patients will experience considerable sinonasal symptoms following transnasal endoscopic skull base surgery. Postnasal discharge and thick nasal discharge improve significantly over time. Symptoms approach baseline by 6 to 9 months following surgery.

Management of Sinonasal Malignant Neoplasms: Defining the Role of Endoscopy

Background

Preliminary reports support the role of endoscopic techniques in the management of selected sinonasal malignancies. The objectives of this review are (1) to assess outcomes for patients undergoing definitive endoscopic tumor extirpation and (2) to elucidate the role of endoscopy in the management of sinonasal malignancies.

Methods

Retrospective review of patients with sinonasal malignancy managed via endoscopic techniques from September 1998 to December 2007 was conducted.

Results

Sixty-one patients were identified (38 men and 23 women) with a mean age of 59 years. The five most common pathologies were squamous cell carcinoma (21), melanoma (10), esthesioneuroblastoma (8), adenocarcinoma (7), and sinonasal undifferentiated carcinoma (3). Sixty-nine endoscopic procedures were performed and categorized according to surgical intent: 57 curative resections (82.6%), 8 palliative resections (11.6%), and 4 tumor mappings (5.8%). Adjuvant chemotherapy and/or radiation therapy was used in 29 of the 50 patients (58%). For those patients undergoing definitive treatment, the disease-free and overall survival rates were 69.2 and 84.6% at mean of 34.5 and 42.7 months, respectively. The local and regional recurrence rates were 17 and 10%, respectively.

Conclusion

The endoscope is a versatile tool for management of sinonasal malignant neoplasms. Although the role was once just limited to biopsy, endoscopic approaches allow for definitive resection for curative intent and palliative resection for patient comfort with acceptable survival. Moreover, endoscopy facilitates three-dimensional tumor mapping and posttreatment surveillance in patients undergoing definitive chemoradiation.

Outcomes of minimally invasive endoscopic resection of anterior skull base neoplasms

OBJECTIVES/HYPOTHESIS

The objective of this study was to review clinical outcomes of minimally invasive endoscopic resection (MIER) for anterior skull base (ASB) neoplasms.

STUDY DESIGN

Retrospective data review.

METHODS

Data analysis was performed on all patients undergoing MIER from October 2000 to December 2008.

RESULTS

Thirty-one patients with mean age of 58 years underwent MIER. Malignant and benign tumors were managed in 25 (80.6%) and six (19.4%) cases, respectively. Most common histopathologies were squamous cell carcinoma (six), esthesioneuroblastoma (five), mucosal melanoma (five), and sinonasal undifferentiated carcinoma (four). American Joint Committee on Cancer tumor staging was T3N0M0 and T4N0M0 in 14 (56%) and 11 (44%) of the malignant cases, respectively. Surgical resection with curative intent was performed in 28 cases (90.3%). Multilayered skull base reconstruction was performed in most patients; lumbar drains were used in eight cases (25.8%). Twenty-one patients (67.7%) were disease free, five patients (16.1%) were dead from disease, three patients (9.7%) were alive with disease, and two patients (6.5%) died from unrelated causes at mean follow-up of 31.7 months.

CONCLUSIONS

This study validated technical feasibility of MIER for diversity of benign and malignant ASB histopathology. Majority of patients were able to avoid adjunct craniotomy, whereas lumbar drainage was utilized in selective cases. This surgical strategy resulted in low complication rate and acceptable disease-free survival in patients with advanced T3 and T4 malignant lesions. Future studies should focus on multicenter trials to facilitate more robust survival analysis and comparison to open surgical approaches.

Endoscopic endonasal skull base surgery: past, present and future

Endoscopic techniques have undergone tremendous advancement in the past years. From the management of phlogistic pathologies, we have learned to manage skull base lesions and even selected intracranial diseases. Current anatomical knowledge plus computer-aided surgery has enabled surgeons to remove large lesions in the paranasal sinuses extending beyond the boundaries of the sinuses themselves. In this sense, management of benign diseases via endoscopic routes is nowadays well accepted whilst the role of endoscopic techniques in sinonasal malignancies is still under investigation. Nowadays, it is possible to tackle different pathologies placed not only in the ventral skull base, but also extended laterally (infratemporal fossa and petrous apex) and even, in really selected cases, within the orbit. The ability to resect and reconstruct has improved significantly. At the moment, the improvement in surgical techniques, like the four-handed technique, has rendered endoscopic procedures capable of managing complex pathologies, according the same surgical principles of the open approaches. From now onwards, frameless neuronavigation, modular approaches, intraoperative imaging systems and robotic surgery are and will be an increasingly important part of endonasal surgery, and they will be overtaken by further evolution.

Endoscopic anatomy of sphenoid sinus for pituitary surgery

Endoscopic endonasal transsphenoidal approach to the sellar region yields an alternative to classical microsurgical approaches. Endoscopes provide images that differ from microscopic view. This study aimed to highlight surgical landmarks and their anatomical relationships for pituitary surgery through endoscopic perspective. Ten sides of five adult cadaveric heads with red-colored latex injected arteries were evaluated. Endoscopic dissections were performed and measurements were done in the sphenoid sinuses before and after the removal of bony structures in all the aspects. Endoscopic vision of the sellar region enabled a wide panoramic perspective and detailed inspection. The measurements, in general, indicated the variations in the bony structures and soft tissues. The width of the pituitary, which is the distance between the medial margins of the carotid prominences, was measured as 21 +/- 2.5 mm and the distance between the medial margin of the carotid prominences at the lower margin of the pituitary was 18 +/- 3.1 mm. After the bony structures were removed, further measurements were done. The width of the pituitary, which is the distance between the medial margins of the anterior curvature of the ICA, was measured as 23.2 +/- 3 mm, while the distance between the posterior curvature of the ICA was 19.7 +/- 4.9 mm. Endoscopic view provided superior detailed visualization of the close relationships between pituitary gland, internal carotid arteries, and optic nerves. This facilitated exact evaluation for variations, which could result in more effective and safe surgery. However, these variations again emphasize the necessity of preoperative radiological evaluation in each case.

Minimally invasive pituitary surgery

OBJECTIVES/HYPOTHESIS

Surgical approaches to the pituitary have undergone numerous refinements over the last 100 years. The introduction of the endoscope and the advent of minimally invasive pituitary surgery (MIPS) have revolutionized pituitary surgery. This study aims to compile and evaluate outcomes of all of the MIPS performed at our institution.

STUDY DESIGN

Retrospective, cases series of 176 consecutive patients undergoing MIPS.

METHODS

Patient demographics, tumor characteristics, and intraoperative or postoperative complications for of 176 consecutive patients undergoing MIPS were complied. Statistical analysis for categorical variables and incidence across series were conducted using Pearson's chi test and Fisher's exact tests. Odd ratios were calculated to relate the discrete variables to outcomes and designing clinical prediction of risk.

RESULTS

One hundred seventy-six patients who underwent 193 procedures. Pathologic evaluation revealed 147 of the tumors to be pituitary adenomas. Only one death occurred (mortality rate of 0.5%). The rate of diabetes insipidus occurred in 20.2% of the procedures. Vascular complications occurred in 5.2% of the procedures. Intraoperative cerebrospinal fluid (CSF) leaks were identified in 19.7% whereas postoperative CSF leak was noted in 10.3%. Resection of Rathke's cleft cyst correlated higher risk of both intraoperative and postoperative CSF leak (OR = 2.6, P <.001). Resection of tumors other than adenomata correlated with significantly higher risk of CSF leak (OR = 9.0, P = <.001). Sinusitis occurred after eleven resections (5.7%). Meningitis occurred in 2 of 193 resections (1.0%) in our series. Two neurologic complications occurred in our series, pneumocephalus and cranial neuropathy (1.0%). No other complications occurred.

CONCLUSIONS

MIPS is a safe and efficacious marriage of the endoscope to the transsphenoidal approach. Thus, a brightness and clarity of vision is combined with the unique ability to explore the tumor bed with angled views and hydroscopy. Outcomes and complication rates comparable to traditional transsphenoidal approaches have resulted but with less dissection and tissue manipulation, reduced need for packing, and greater patient comfort and acceptance.

Endoscopic transnasal craniotomy and the resection of craniopharyngioma

OBJECTIVES/HYPOTHESIS

To describe the utility of a large transnasal craniotomy and its reconstruction in the surgical management of patients with craniopharyngioma.

STUDY DESIGN

Observational retrospective cohort study.

METHODS

Retrospective review of patients treated in an academic neurosurgery/rhinology practice between 2000 and 2007. Patient characteristics (age, sex, follow-up), tumor factors (size, position extension, previous surgery), type of repair (pedicled mucosal flaps, free mucosal grafts), and outcomes (visual, endocrine, and surgical morbidity) were defined and sought in patients who had an entirely endoscopic resection of extensive craniopharyngioma (defined as requiring removal of the planum sphenoidale in addition to sella exposure in the approach).

RESULTS

Seven patients had an entirely endoscopic resection of extensive craniopharyngioma during the study period. Mean age was 23.4 years (standard deviation +/- 16.3). Mean tumor size was 3.2 cm (standard deviation +/- 2.0). The majority of these pathologies had extensive suprasellar disease, and two (28.6%) had ventricular disease. Cerebrospinal fluid leak rate was 29% (2 of 7). These leaks occurred only in reconstructions with free mucosal grafts. There were no cerebrospinal fluid leaks in patients who had vascularized pedicled septal flap repairs.

CONCLUSIONS

The endoscopic management of large craniopharyngioma emphasizes recent advancements in endoscopic skull base surgery. The ability to provide exposure through a large (4 cm+) transnasal craniotomy, near-field assessment of neurovascular structures, and the successful reconstruction of a large skull defect have significantly advanced the field in the past decade. The use of a two-surgeon approach and bilateral pedicled septal mucosal flaps have greatly enhanced the reliability of this approach.

Endoscopic transnasal transethmosphenoidal approach for pituitary tumors: assessment of technique and postoperative findings of nasal and paranasal cavities

OBJECTIVE

Transnasal endoscopic surgery is the most common approach to removal of pituitary tumors. This study evaluated the transnasal transethmosphenoidal approach (TTES) in terms of its operative manipulability and the postoperative status of the paranasal cavities.

METHODS

A total of 132 patients with pituitary tumors underwent surgery by one of the following three approaches: (1) bilateral TTES, in which the surgical procedures were performed via the bilateral paranasal cavities, (2) unilateral TTES, in which the procedures were performed via one side only, and (3) unilateral TTES and resection of the posterior portion in the nasal septum approach (RPS), which is a modification of approach (2) and enables performance of the procedures from both sides.

RESULTS

The degree of freedom for the surgical procedures with each of the approaches decreased in the following order: bilateral TTES, unilateral TTES and RPS, and unilateral TTES. The postoperative CT images and endoscopic findings were good with each of the surgical approaches, but the incidences of olfactory disturbance and nasal dryness were significantly higher with the bilateral TTES compared with the unilateral TTES and RPS and the unilateral TTES.

CONCLUSION

The unilateral TTES and RPS was for us most suitable approach of the three methods. In the case of advanced tumors, the bilateral TTES should be selected because it permits superior operative manipulability. Finally, the unilateral TTES is most appropriate for removal of tumors that are deviated to one side and localized within the sella.