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Ilya Laufer, Vijay K. Anand and Theodore H. Schwartz

Object

The extended transsphenoidal approach is a less invasive method for removing purely suprasellar lesions compared with traditional transcranial approaches. Most advocates have used a sublabial incision and a microscope and have reported a significant risk of cerebrospinal fluid (CSF) leakage. The authors report on a series of purely endoscopic endonasal surgeries for resection of suprasellar supradiaphragmatic lesions above a normal-sized sella turcica with a low risk of CSF leakage.

Methods

A purely endoscopic endonasal approach was used to remove suprasellar lesions in a series of 10 patients. Five lesions were prechiasmal (three tuberculum sellae and two planum sphenoidale meningiomas) and five were post-chiasmal (four craniopharyngiomas and one Rathke cleft cyst). The floor of the planum sphenoidale and the sella turcica was reconstructed using a multilayer closure with autologous and synthetic materials. Spinal drainage was performed in only five cases. Complete resection of the lesions was achieved in all but one patient. The pituitary stalk was preserved in all but one patient, whose stalk was invaded by a craniopharyngioma and who had preoperative diabetes insipidus (DI). Vision improved postoperatively in all patients with preoperative impairment. Six patients had temporary DI; in five, the DI became permanent. Four patients with craniopharyngiomas required cortisone and thyroid replacement. After a mean follow up of 10 months, there was only one transient CSF leak when a lumbar drain was clamped prematurely on postoperative Day 5.

Conclusions

A purely endoscopic endonasal approach to suprasellar supradiaphragmatic lesions is a feasible minimally invasive alternative to craniotomy. With a multilayer closure, the risk of CSF leakage is low and lumbar drainage can be avoided. A larger series will be required to validate this approach.

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Edward D. McCoul, Vijay K. Anand and Theodore H. Schwartz

Object

Endoscopic skull base surgery (ESBS) is a minimal-access technique that provides an alternative to traditional approaches. Patient-reported outcomes are becoming increasingly important in measuring the success of surgical interventions. Endoscopic skull base surgery may lead to improvements in quality of life (QOL) since natural orifices are used to reach the pathology; however, sinonasal QOL may be negatively affected. The purpose of this study was to assess the impact of ESBS on both site-specific QOL, using the Anterior Skull Base Questionnaire (ASBQ), and sinonasal-related QOL, using the Sino-Nasal Outcome Test (SNOT-22).

Methods

Consecutive patients from a tertiary referral center who were undergoing ESBS were prospectively enrolled in this study. All patients completed the ASBQ and SNOT-22 preoperatively as well as at regular intervals after ESBS.

Results

Sixty-six patients were included in the study, and 57.6% of them had pituitary adenoma. There was no significant decline or improvement in the ASBQ-measured QOL at 3 and 6 weeks after ESBS, but there were significant improvements at 12 weeks and 6 months postoperatively (p < 0.05). Improvements were noted in all but one ASBQ subdomain at 12 weeks and 6 months postsurgery (p < 0.05). Preoperative QOL was significantly worse in patients who had undergone revision surgery and significantly improved postoperatively in patients who underwent gross-total resection (p < 0.05). Scores on the SNOT-22 worsened at 3 weeks postoperatively and returned to baseline thereafter. The presence of a nasoseptal flap or a graft-donor site did not contribute to a decreased QOL.

Conclusions

Endoscopic skull base surgery is associated with an improvement in postoperative site-specific QOL as compared with the preoperative QOL. Short-term improvements are greater if gross-total resection is achieved. Sinonasal QOL transiently declines and then returns to preoperative baseline levels. Endoscopic skull base surgery is a valuable tool in the neurosurgical management of anterior skull base pathology, leading to improvements in site-specific QOL.

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Justin F. Fraser, Vijay K. Anand and Theodore H. Schwartz

✓The authors present the case of a 71-year-old man who presented with neck pain, a history of gout, and a mass in the dens. Results of transoral endoscopic biopsy sampling demonstrated tophaceous gout. The patient was treated medically and the pain resolved. Tophaceous gout isolated in the dens is extremely rare and should be considered in the differential diagnosis of masses in this region. With the aid of transoral or transnasal endoscopic biopsy sampling, the diagnosis can be reached in a minimally invasive manner.

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Tomasz A. Dziedzic, Vijay K. Anand and Theodore H. Schwartz

Although the medial and inferior orbital apex are considered safely accessible using the endonasal endoscopic approach, the lateral apex has been considered unsafe to access since the optic nerve lies between the surgeon and the pathology. The authors present the case of a 4-year-old girl with recurrent rhabdomyosarcoma attached to the lateral rectus muscle located lateral and inferior to the optic nerve in the orbital apex. The tumor was totally resected through an endoscopic endonasal transmaxillary transpterygoidal approach using a 45° endoscope. A gross-total resection was achieved, and the patient’s vision was unchanged. This procedure is a safe, minimal-access alternative to open procedures in selected cases and provides evidence that increases the applicability of the endonasal endoscopic approach to reach the lateral compartment of the orbital apex.

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Justin F. Fraser, Gurston G. Nyquist, Nicholas Moore, Vijay K. Anand and Theodore H. Schwartz

Object

Transcranial approaches to clival chordomas provide a circuitous route to the site of origin of the tumor often involving extensive bone drilling and brain retraction, which places critical neurovascular structures between the surgeon and pathology. For certain chordomas, the endonasal endoscopic transclival approach is a novel minimal access, but it is an equally aggressive alternative providing the most direct route to the tumor epicenter.

Methods

The authors present a consecutive series of patients undergoing endonasal endoscopic resection of clival chordomas. Extent of resection was determined by postoperative volumetric MR imaging and divided into > 95% and < 95%.

Results

Seven patients underwent 10 operations. Preoperative cranial neuropathies were present in 4. The mean patient age was 52.0 years. The mean tumor volume was 34.9 cm3. Intraoperative lumbar drainage was used in 1 patient, and the tumors extended intradurally in 3. One patient underwent 2 intentionally palliative procedures for subtotal debulking. Greater than 95% resection was achieved in 7 of 8 operations in which radical resection was the goal (87%). All tumors with volumes < 50 cm3 had > 95% resection (p = 0.05). The overall mean follow-up was 18.0 months. Cranial neuropathies resolved in all 3 patients with cranial nerve VI palsies. One patient with recurrent nasopharyngeal chordoma died of disease progression; another experienced 2 recurrences before receiving radiation therapy. All surviving patients remain progression free. There were no intraoperative complications; however, 1 patient developed a pulmonary embolus postoperatively. There were no postoperative CSF leaks.

Conclusions

The endonasal endoscopic transclival approach represents a less invasive and more direct approach than a transcranial approach to treat certain moderate-sized midline skull base chordomas. Longer follow-up is necessary to determine comparability to transcranial approaches for long-term control. Large tumors with significant extension lateral to the carotid artery may not be suitable for this approach.

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Abtin Tabaee, Vijay K. Anand, Paolo Cappabianca, Aldo Stamm, Felice Esposito and Theodore H. Schwartz

Object

Spontaneous meningoencephaloceles of the lateral sphenoid sinus are rare lesions that are hypothesized to result from persistence of the lateral craniopharyngeal canal. Prior reports of the management of this lesion have been limited by its relative rarity. The objective of this paper is to report the theoretical etiology, surgical technique, and outcomes in patients undergoing endoscopic repair of spontaneous meningoencephalocele of the sphenoid sinus.

Methods

The authors conducted a retrospective review of a multiinstitutional series of 13 cases involving patients who underwent endoscopic repair of spontaneous meningoencephalocele of the lateral sphenoid sinus. The surgical technique and pathophysiological considerations are discussed.

Results

The clinical manifestations included CSF rhinorrhea (85%), chronic headache (77%), and a history of meningitis (15%). The endoscopic approaches to the lateral sphenoid sinus were transnasal (39%), transpterygoid (23%), and transethmoid (39%). Two patients (8%) had postoperative CSF leaks, one of which closed spontaneously and one of which required revision endoscopic closure. All patients were free of leak at most recent follow-up. One patient experienced postoperative meningitis in the early postoperative period.

Conclusions

Endoscopic endonasal closure is an effective modality in the treatment of spontaneous meningoencephaloceles of the lateral sphenoid sinus. If the sphenoid sinus has extensive lateral pneumatization, adequate exposure may require a transpterygoid approach.

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Ilya Laufer, Jeffrey P. Greenfield, Vijay K. Anand, Roger Härtl and Theodore H. Schwartz

✓The authors report a case of a nonachnodroplastic dwarf with severe basilar invagination and compression of the cervicomedullary junction (CMJ) due to juvenile rheumatoid arthritis. Initially excellent reduction of the invagination and decompression of the CMJ was achieved using posterior fixation. However, 1 month postoperatively symptoms recurred and the authors found imaging evidence of recurrence as well. The patient subsequently underwent an endoscopic transnasal resection of the dens with assistance of Iso-C navigation. He recovered well and tolerated regular diet on postoperative Day 2.

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Edward D. McCoul, Jeffrey C. Bedrosian, Olga Akselrod, Vijay K. Anand and Theodore H. Schwartz

OBJECT

Pituitary adenomas are well suited to resection by a minimal-access endoscopic technique. Validation of this approach requires prospective outcome studies to determine the impact on quality of life (QOL). This study aims to assess the effect of endoscopic pituitary adenoma resection on site-specific and sinonasal-related QOL before and after endoscopic surgery using validated instruments.

METHODS

Consecutive adult patients undergoing endoscopic endonasal resection of pituitary adenoma were prospectively enrolled from a single tertiary care center. All patients completed the Anterior Skull Base Questionnaire (ASBQ) and the 22-Item Sino-Nasal Outcome Test (SNOT-22) preoperatively and then at regular intervals after surgery to assess their perceived QOL with regard to hormonal, surgical, and anatomical factors.

RESULTS

Eighty-one of 114 patients were eligible for study; median follow-up was 16 months. This cohort included 24 (29.6%) nonsecreting macroadenomas and 57 (70.4%) hypersecreting tumors. There was significant improvement in the mean ASBQ score at 12 weeks, 6 months, and 1 year after surgery (p < 0.05), while postoperative SNOT-22 scores, at the same time points, showed no significant difference from preoperative scores. Both ASBQ and SNOT-22 scores showed transient worsening at 3 weeks postoperatively. Subtotal resection correlated with worse QOL, both overall and among patients with hypersecreting tumors (p < 0.05). Extrasellar tumor extension, intraoperative CSF leakage, and a reconstruction technique during surgery did not impact postoperative QOL. Visual disturbances did not significantly alter QOL. There were no postoperative CSF leaks in this series.

CONCLUSIONS

Endoscopic resection of pituitary adenoma is associated with long-term improvements in site-specific QOL and stability in sinonasal QOL when assessed pre- and postoperatively with validated instruments. Subtotal resection was the only factor that negatively impacted postoperative QOL. Therefore, gross-total resection should be attempted for all patients to optimize QOL after surgery.

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Matei A. Banu, Oszkar Szentirmai, Lino Mascarenhas, Al Amin Salek, Vijay K. Anand and Theodore H. Schwartz

Object

Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS.

Methods

The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1–10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0–4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak.

Results

The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed “suspicious” pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as “benign” pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0–4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of “suspicious” pneumocephalus provides the best overall prediction for postoperative CSF leaks.

Conclusions

Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A “suspicious” pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of “suspicious” pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.