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–3 2. Stammberger H : Endoscopic endonasal surgery — concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngol Head Neck Surg 94 : 147 – 156 , 1986 Stammberger H: Endoscopic endonasal surgery — concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngol Head Neck Surg 94: 147–156, 1986

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Hae-Dong Jho and Ricardo L. Carrau

. Am J Otolaryngol 14 : 254 – 256 , 1993 Shikani AH, Kelly JH: Endoscopic debulking of a pituitary tumor. Am J Otolaryngol 14: 254–256, 1993 18. Stammberger H : Endoscopic endonasal surgery—concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngol Head Neck Surg 94 : 147 – 156 , 1986 Stammberger H: Endoscopic endonasal surgery—concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngol Head Neck Surg 94: 147–156, 1986 19. Stevens MH

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Gabriel Zada, Daniel F. Kelly, Pejman Cohan, Christina Wang and Ronald Swerdloff

with the transseptal endonasal approach, postoperative complaints of pain and numbness were noted by 50 and 50% of patients, respectively, after the sublabial approach, and by 25 and 75% of patients, respectively, after the transseptal approach. 42 Details concerning the severity, location, and duration of these complaints, however, were not provided. Comparison With the Endoscopic Endonasal Approach Jho and Carrau 20 in 1997 and Jho 19 in 2001 reported their experiences with patients undergoing purely endoscopic endonasal surgery for a variety of sellar

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Luigi M. Cavallo, Andrea Messina, Paolo Cappabianca, Felice Esposito, Enrico de Divitiis, Paul Gardner and Manfred Tschabitscher

Object

The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens.

Methods

To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach.

Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable.

Conclusions

The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach.

Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

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.3171/foc.2005.19.1.2 FOC.2005.19.1.2 Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations Luigi M. Cavallo Andrea Messina Paolo Cappabianca Felice Esposito Enrico de Divitiis Paul Gardner Manfred Tschabitscher 7 2005 19 1 1 14 10.3171/foc.2005.19.1.3 FOC.2005.19.1.3 Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica Amin Kassam Carl H. Snyderman Arlan Mintz Paul Gardner Ricardo L. Carrau 7 2005 19 1 1 12 10.3171/foc.2005.19.1.4 FOC.2005.19.1.4 Expanded endonasal approach

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Amin Kassam, Ajith J. Thomas, Carl Snyderman, Ricardo Carrau, Paul Gardner, Arlan Mintz, Hilal Kanaan, Michael Horowitz and Ian F. Pollack

29 Stammberger H : Endoscopic endonasal surgery—concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique . Otolaryngol Head Neck Surg 94 : 147 – 156 , 1986 30 Teo C , Dornhoffer J , Hanna E , Bower C : Application of skull base techniques to pediatric neurosurgery . Childs Nerv Syst 15 : 103 – 109 , 1999 31 Weiss MH , The transnasal transphenoidal approach . Apuzzo ML : Surgery of the Third Ventricle Baltimore , Williams & Wilkins , 1987 . 476 – 494

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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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Daniel M. Prevedello, Francesco Doglietto, John A. Jane Jr., Jay Jagannathan, Joseph Han and Edward R. Laws Jr.

, Tschabitscher M : Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study . Neurosurgery 56 : 2 Suppl 379 – 389 , 2005 22 Cavallo LM , Messina A , Cappabianca P , Esposito F , de Divitiis E , Gardner P , : Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations . Neurosurg Focus 19 : 1 E2 , 2005 23 Cavallo LM , Messina A , Gardner P , Esposito F , Kassam AB , Cappabianca P , : Extended endoscopic endonasal approach to the pterygopalatine

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Amir R. Dehdashti and Fred Gentili

purely endoscopic endonasal surgery with a 0° endoscope with a lens diameter of 4 mm (Karl Storz GmbH & Co. KG). This approach has been described elsewhere 9 but will be briefly discussed here. The operation takes place while a patient is supine with his or her head fixed in a three-pin Mayfield holder. The head of the bed is elevated, and the neck is slightly extended and rotated toward the right side. Frameless stereotactic navigation with the Stealth machine (Medtronic) is used for anatomical guidance. Note that C-arm fluoroscopy is not used because

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Franco DeMonte and Ehab Hanna

, Gardner P , : Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations . Neurosurg Focus 19 : 1 E2 , 2005 4 Cavallo LM , Messina A , Gardner P , Esposito F , Kassam AB , Cappabianca P , : Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations . Neurosurg Focus 19 : 1 E5 , 2005 5 Chummun S , McLean NR , Kelly CG , Dawes PJ , Meikle D , Fellows S , : Adenoid cystic carcinoma of the head and neck . Br J Plast Surg