New developments in transnasal endoscopic surgery for malignancies of the sinonasal tract and adjacent skull base

[Endoscopic endonasal anterior skull base surgery : Presentation of a monocentric entity profile]

BACKGROUND

Extended endoscopic endonasal surgery (EEES) is an essential part of treatment of various pathologies of the anterior skull base. In addition to significant improvements in the quality of life of affected patients and a lower complication profile compared to open skull base surgery, the therapeutic results are comparable if the indications are correct.

MATERIALS AND METHODS

Data of all endoscopic endonasal skull base procedures performed at the University Skull Base Center Hamburg under the direction of the Department of Otorhinolaryngology between June 2018 and November 2022 were retrospectively collected.

RESULTS

A total of 50 cases were identified. Of these, 56% (28/50) were malignant tumors, 24% (12/50) were benign pathologies with direct skull base involvement, and 20% (10/50) were anterior skull base defects with rhinoliquorrhea. In 96% (48/50) of cases, the preoperatively set goal of surgery (representative biopsy, complete resection, closure of the skull base defect) could be achieved. Complications grade III or higher according to Clavien-Dindo occurred in 4/50 cases. During the observation period, n = 5 olfactory neuroblastomas were diagnosed, all of which were exclusively and successfully operated on endoscopically.

CONCLUSION

In recent years, the spectrum of endoscopically resectable pathologies of the anterior skull base has steadily expanded. In particular, midline-related tumors such as olfactory neuroblastoma or iatrogenic/idiopathic skull base defects with cerebrospinal fluid rhinorrhea are treated completely endoscopically with very good results. Nevertheless, there are also limitations to this technique. Due to high variance in the scope of frontobasal surgery, the extent, and the complex anatomy, as well as the overlapping responsibilities of the specialist disciplines, establishment of certified skull base centers and bundling of frontobasal surgery at these centers is highly relevant for quality assurance.

An Endoscopic Endonasal Nasopharyngectomy with Posterolateral Extension

Background Invasion depth influences the choice for extirpation of nasopharyngeal malignancies. This study aims to validate the feasibility of endoscopic endonasal resection of lesions with a posterolateral invasion. As a secondary goal, the study intends to propose a classification system of endoscopic endonasal nasopharyngectomy determined by the depth of posterolateral invasion.

Methods Eight cadaveric specimens (16 sides) underwent progressive nasopharyngectomy using an endoscopic endonasal approach. Resection of the torus tubarius, Eustachian tube (ET), medial pterygoid plate and muscle, lateral nasal wall, and lateral pterygoid plate and muscle were sequentially performed to expose the fossa of Rosenmüller, petroclival region, parapharyngeal space (PPS), and jugular foramen, respectively.

Results Technical feasibility of endonasal nasopharyngectomy toward a posterolateral direction was validated in all 16 sides. Nasopharyngectomy was classified into four types as follows: (1) type 1: resection restricted to the posterior or superior nasopharynx; (2) type 2: resection includes the torus tubarius which is suitable for lesions extended into the petroclival region; (3) type 3: resection includes the distal cartilaginous ET, medial pterygoid plate, and muscle, often required for lesions extending laterally into the PPS; And (4) type 4: resection includes the lateral nasal wall, pterygoid plates and muscles, and all the cartilaginous ET. This extensive resection is required for lesions involving the carotid artery or extending to the jugular foramen region.

Conclusion Selected lesions with posterolateral invasion into the PPS or jugular foramen is amenable to a resection via expanded endonasal approach. Classification of nasopharyngectomy based on tumor depth of posterolateral invasion helps to plan a surgical approach.

The Role of Advanced Endoscopic Resection of Diverse Skull Base Malignancies: Technological Analysis during an 8-Year Single Institutional Experience

Background  Resection of skull base malignancies poses complex pathological and treatment-related morbidities. Recent technological advancements of endoscopic endonasal surgery (EES) offer the ability to reexamine traditional treatment paradigms with endoscopic procedures. The utility of EES was quantitatively examined in a longitudinal series with attention to morbidities and postoperative outcomes. Methods  A single-center retrospective review was performed of all malignant sinonasal tumors from 2010 to 2018. Patients with purely EES were selected for analysis. Disease features, resection extent, complications, adjuvant treatment, recurrence, and survivability were assessed. Despite the mixed pathological cohort, analysis was performed to identify technical aspects of resection. Results  A total of 68 patients (47.6% males and 52.4% females, average age: 60.3 years) were included. A diversity of histotypes included clival chordoma (22.1%), olfactory neuroblastoma (14.7%), squamous cell carcinoma (11.8%), and adenoid cystic carcinoma (11.8%). Gross total resection (GTR) was achieved in 83.8% of cases. Infection (4.4%) and cerebrospinal fluid leak (1.5%) were the most common postoperative complications. Total 46 patients (67.6%) underwent adjuvant treatment. The average time between surgery and initiation of adjunctive surgery was 55.7 days. Conclusion  In our 8-year experience, we found that entirely endoscopic resection of mixed pathology of malignant skull base tumors is oncologically feasible and can be accomplished with high GTR rates. There may be a role for EES to reduce operative morbidity and attenuate time in between surgery and adjuvant treatment, which can be augmented through recent mixed reality platforms. Future studies are required to systematically compare the outcomes with those of open surgical approaches.

Postoperative epistaxis and sphenoid sinus ostial stenosis after posterior septal branch injury during sphenoidotomy

BACKGROUND

Postoperative arterial epistaxis and sphenoid sinus stenosis after sphenoidotomies for endoscopic sinus surgery (ESS) and transsphenoidal approaches (TSAs) are uncommon. One potential source of epistaxis after sphenoidotomy is the sphenopalatine artery's posterior septal branch (PSB). PSB injury, in addition to other factors, could increase the risk of sphenoid stenosis. The purpose of this study was to determine incidence of, and risks factors for, the following outcomes after sphenoidotomy: PSB injury; postoperative epistaxis from the injured PSB; and sphenoid stenosis after PSB injury.

METHODS

A single-institution, prospective case series was conducted based on 233 sphenoidotomies performed during ESS (n = 163) and TSAs (n = 70). Outcome measures included intraoperative PSB injury, postoperative epistaxis from the PSB, and sphenoid stenosis.

RESULTS

The incidence of PSB injury was 17.2% during ESS-related sphenoidotomies, and 5.7% during TSA-related sphenoidotomies (p = 0.010). After PSB injury during ESS- and TSA-related sphenoidotomies (n = 32), there was 1 instance of epistaxis from the PSB (3.1%). Of the 161 ESS-related sphenoidotomies, 6 developed complete or near-complete stenosis (3.7%), which was more likely to occur with smaller anterior sphenoid face dimensions (p = 0.001). PSB injury, revision sphenoidotomy, and other factors did not increase the risk of stenosis. None of the TSA-related sphenoidotomies stenosed completely. Median follow-up was 7 months.

CONCLUSION

PSB injury occurred in 17.2% of ESS-related sphenoidotomies and 5.8% of TSA-related sphenoidotomies. After PSB injury, postoperative epistaxis from the PSB was rare (3.1%). After ESS-related sphenoidotomies, sphenoid stenosis was rare (3.7%), and was more likely to occur with smaller sphenoid dimensions, but not with PSB injury or other factors.

Endoscopic anterior transmaxillary "transalisphenoid" approach to Meckel's cave and the middle cranial fossa: an anatomical study and clinical application

OBJECTIVE Multiple approaches have been designed to reach the medial middle fossa (for lesions in Meckel's cave, in particular), but an anterior approach through the greater wing of the sphenoid (transalisphenoid) has not been explored. In this study, the authors sought to assess the feasibility of and define the anatomical landmarks for an endoscopic anterior transmaxillary transalisphenoid (EATT) approach to Meckel's cave and the middle cranial fossa. METHODS Endoscopic dissection was performed on 5 cadaver heads injected intravascularly with colored silicone bilaterally to develop the approach and define surgical landmarks. The authors then used this approach in 2 patients with tumors that involved Meckel's cave and provide their illustrative clinical case reports. RESULTS The EATT approach is divided into the following 4 stages: 1) entry into the maxillary sinus, 2) exposure of the greater wing of the sphenoid, 3) exposure of the medial middle fossa, and 4) exposure of Meckel's cave and lateral wall of the cavernous sinus. The approach provided excellent surgical access to the anterior and lateral portions of Meckel's cave and offered the possibility of expanding into the infratemporal fossa and lateral middle fossa and, in combination with an endonasal transpterygoid approach, accessing the anteromedial aspect of Meckel's cave. CONCLUSIONS The EATT approach to Meckel's cave and the middle cranial fossa is technically feasible and confers certain advantages in specific clinical situations. The approach might complement current surgical approaches for lesions of Meckel's cave and could be ideal for lesions that are lateral to the trigeminal ganglion in Meckel's cave or extend from the maxillary sinus, infratemporal fossa, or pterygopalatine fossa into the middle cranial fossa, Meckel's cave, and cavernous sinus, such as schwannomas, meningiomas, and sinonasal tumors and perineural spread of cutaneous malignancy.

Transnasal Endoscopic Biopsy Approach to Atlas Tumor with X-ray Assisted and Related Radiographic Measure

OBJECTIVE

To develop an endoscopic transnasal approach to atlas tumors and study its practicability.

METHODS

This article comprises two components: an illustrative case report and observational data on 50 volunteers. As to the case report, a 34 year old man presented with occipital pain for more than 3 months and underwent systematic investigation in Qilu Hospital of Shandong University. CT and MRI scans showed bony destruction in the craniovertebral junction (CVJ) suggestive of tumor. Via an endoscopic transnasal approach to the suspected atlas tumor through the inferior nasal meatus, a Gallini biopsy needle was used to obtain tissue for examination. The procedure was performed endoscopically with double orientation X-ray guidance and coaxial technology after establishing the shortest distance for the biopsy track and range of target tissue and was assisted by manual palpation. As to the observational data, 50 volunteers underwent atlas-related morphometric image measurement using gemstone CT equipment. Biopsy track angles, range for biopsy of the atlas and biopsy track distances were measured by a blinded operator on CT images.

RESULTS

CASE REPORT

pathological examination of the biopsy resulted in diagnosis of a chordoma. There were no complications such as bleeding, infection or spinal cord injury. One month later, the patient underwent tumor resection and reconstruction in other hospital and the diagnosis of chordoma was confirmed by pathological examination of the resected specimen. Observational data: measurements obtained from CT scans of the 50 volunteers were as follows. Biopsy track angles: mean leaning inside angle 3.53° ± 0.39° and mean posterior slope angle 13.05° ± 1.39°. Range for atlas biopsy: transverse diameter 11.84 ± 1.24 mm and longitudinal diameter 9.67 ± 0.90 mm. Biopsy track distances: from atlas to nostril, and to anterior and posterior edges of the inferior turbinate mucosa were 94.52 ± 5.03 mm, 78.21 ± 4.63 mm, and 33.51 ± 3.13 mm, respectively.

CONCLUSIONS

An endoscopic transnasal approach enables biopsy and diagnosis of tumors in the anterior arch of the atlas. Relevant measurements were obtained by assessing CT scans of 50 volunteers to assist operators to determine the effective and safe range for transnasal atlas biopsy.

The use of a three-dimensional endoscope for different skull base tumors: results of a preliminary extended endonasal surgical series

BACKGROUND

The evolution of skull base surgery over the past decade has been influenced by advancement in visualization technology. Recently, as a result of such improvements, three-dimensional (3-D) scopes have been widely used during endoscopic endonasal approaches. In the present study, we describe the use of 3-D stereoscopic endoscope for the treatment of a variety of skull base lesions.

METHODS

From January 2010 to June 2015, a 3-D endoscopic endonasal approach (4 and 4.9 mm, 0°, and 30° rigid endoscopes) was performed in 70 patients with the following lesions: 42 large extrasellar pituitary macroadenomas, seven tuberculum sellae meningiomas, seven clivus chordomas, five craniopharyngiomas, three fibrous dysplasia of the clivus, three sinonasal malignancies, one orbital lymphangioma, one trigeminal neurinoma, one primary suprasellar lymphoma.

RESULTS

Total tumor removal was obtained in 50 patients (71.4 %) while in 14 (20 %), subtotal removal was possible in six (8.6 %) only partial removal was achieved. Overall complications included diabetes insipidus in eight patients (11.4 %), hypopituitarism in seven patients (10 %), CSF leak in five patients (7.1 %), cranial nerve injury in two patients (2.8 %), panhypopituitarism in two patients (2.8 %), meningitis in one (1.4 %) and one postoperative central retinal artery occlusion (1.4 %). There was no mortality in the series. The mean follow-up time was 39 months (range, 6-72 months).

CONCLUSIONS

In our experience, the 3-D endoscope represents a critical development in visualization, thus enabling improved hand-eye coordination and depth perception, which are mandatory for the management of complex intradural neurovascular structures during tumor removal surgery.

Advantages and limitations of endoscopic endonasal approaches to the skull base

BACKGROUND

The anatomy of the skull base is extremely complex with an abundance of critical neurovascular bundles and their corresponding foramina as well as the insertions and origins of multiple masticatory and craniocervical muscles. These anatomic intricacies increase the difficulty of surgery within this area.

METHODS

Advantages and disadvantages of endoscopic endonasal approaches (EEAs) based on the authors' sequential learning and experience are described.

RESULTS

EEAs offer the advantages of using preexistent air spaces that enable accessing various areas of the skull base, while avoiding external incisions or scars and obviating the need for the translocation of the maxillofacial skeleton. In addition, EEAs are well suited to preserve neurologic, visual, and masticatory functions as well as cosmesis. However, the sinonasal corridor must be expanded and optimized to access the skull base adequately, facilitate the reconstruction of the surgical defect, avoid sinonasal complications, and minimize sequelae. Important considerations can limit or indicate the approach, such as the nature of the pathology, including location, diagnosis, and vascularity; patient characteristics, including age and medical comorbidities; surgeon attributes, including training, experience, and expertise; the resultant need to reconstruct large skull base defects and feasible alternatives to do so; and institutional resources, including adjunctive services, an intensive care unit, and operating room equipment.

CONCLUSIONS

EEAs are important techniques in contemporary skull base surgery. Understanding the indications for and limitations of these approaches help to maximize outcomes.

Surgical outcomes of malignant sinonasal tumours: open versus endoscopic surgical approaches

BACKGROUND

Sinonasal malignancies are rare tumours, which can be resected using an open or endoscopic approach. The current study evaluated the outcome of both approaches.

METHODS

A total of 160 patients with malignant nasal tumours were evaluated in an academic tertiary care hospital. The patients were allocated to 'open' or 'endoscopic' surgery groups, based on the surgical approach employed. The following data were evaluated and compared: patient and tumour characteristics; oncological treatments; and oncological outcomes, including complications, surgical margin, recurrence, overall survival and disease-free survival.

RESULTS

The maxillary sinus was the most common tumour location and squamous cell carcinoma was the most common histopathology-based diagnosis. Younger patients had lower grades of tumour. Higher survival rates were significantly related to lower tumour stages in both surgery groups. There were no differences between the two relatively similar groups in terms of surgical margin, the need for adjunctive therapy, and recurrence and survival rates. In addition, multivariate logistical regression analysis indicated no correlations between the type of surgical approach employed and the rates of recurrence and complications.

CONCLUSION

Endoscopic surgery for sinonasal malignancies is comparable to the conventional open approach in carefully selected patients.

Radiosurgery is an Effective Treatment for Recurrent Esthesioneuroblastoma: A Multicenter Study

Objective Esthesioneuroblastoma (ENB) is a rare malignant neuroendocrine neoplasm that is prone to both local and metastatic recurrence. Local recurrence may often be treated with repeat resection. However, stereotactic radiosurgery (SRS) offers a noninvasive option. Design Prospective database review. Participants Gamma knife prospective databases were queried at all institutions within the North American Gamma Knife Consortium, 16 at the time of this report. All patients who had undergone SRS for ENB were included. Main Outcome Measure Response of recurrent ENB to SRS. Results A total of 31 locally recurrent tumors in 13 patients were treated with SRS. The median age was 49 years (range: 19-79 years). At a median follow-up of 36 months (range: 1-100 months), 13 (48%) treated tumors were smaller, 11 (41%) were stable, and 3 (11%) showed continued growth following SRS. Univariate analysis did not find any significant factor relating to failure of treatment. Notably, no treatment-related complications (0%) were observed in this cohort. Conclusion SRS appears to provide a safe and effective option for treatment of recurrent intracranial ENB. Overall, 89% of treated tumors were controlled in this multi-institutional study.

Endoscopic nonembolized resection of an extensive sinonasal cavernous hemangioma: A case report and literature review

Sinonasal hemangiomas, although rare, must be considered in the evaluation of intranasal masses with profuse epistaxis. Although the availability of literature discussing cavernous hemangiomas in this location is limited, there have been no case reports of exclusively soft tissue sinonasal cavernous hemangiomas extending to the anterior skull base (ASB) that were resected purely endoscopically. Here, we describe the successful endoscopic resection of an extensive right sinonasal cavernous hemangioma extending to but not invading the ASB. Although highly vascular, in select cases, these tumors can be successfully resected endoscopically without embolization by experienced endoscopic sinus and skull base surgeons.

Endoscopic resection of sinonasal cancers

Sinonasal malignancies, a rare group of tumors, are characterized by histological heterogeneity and poor survival. As improvements in image-guidance and endoscopic technologies became incorporated into head and neck oncologic and neurosurgical practice, the application of these technologies and techniques to the surgical management of sinonasal malignancy began. Over the past decade, there has been increasing evidence regarding the safety and oncological effectiveness of these techniques. Several institutions have reported their experience with endoscopic surgery and have shown reduced morbidity, better quality of life, and survival outcomes equivalent to those of open surgery in carefully selected patients. Endoscopic cranial base surgery is a rapidly evolving field. We review the literature on oncological outcomes, safety, quality of life, and recent technological advances.

Endoscopic endonasal technique: treatment of paranasal and anterior skull base malignancies

Objective

Method

Conclusion

Long-term outcome of esthesioneuroblastoma: hyams grade predicts patient survival

Object Esthesioneuroblastoma (ENB) is a rare malignant neuroendocrine tumor originating from the olfactory neuroepithelium in the cribriform plate. Controversy still exists regarding the role of pathologic grading (Hyams grade) in prognostication. This study was undertaken to describe our experience with ENB and assess the role of pathologic grading in patient outcome. Methods This was a retrospective, single-institution experience, including 109 patients with ENB treated at our institution from 1962 to 2009. Multivariate analysis was performed utilizing Cox regression analysis models utilizing age, gender, modified Kadish stage, and Hyams grade. Results Mean age was 49 ± 16 (median 50) years at presentation (range 12 to 90 years). Median follow up was 5.1 years. All-cause mortality was significantly influenced by Hyams grading in univariate (p = 0.04) and multivariate (p = 0.02) analysis, in addition to proven prognostic factors, Kadish staging, lymph node metastasis, and age. Median survival was 9.8 years compared with 6.9 years with low (grade 1 to 2) versus high (grade 3 to 4) Hyams grade. Median overall survival was 7.2 ± 0.7 years. Conclusion ENB has a variable outcome, which is primarily prognosticated by the extent of involvement at presentation (Kadish stage and lymph node metastasis) and higher Hyams pathologic grade.

Access to the parapharyngeal space: an anatomical study comparing the endoscopic and open approaches

OBJECTIVES/HYPOTHESIS

A subtemporal preauricular approach to the infratemporal fossa and parapharyngeal space has been the traditional path to tumors of this region. The morbidity associated with this procedure has lead to the pursuit of less invasive techniques. Endoscopic access using a minimally invasive transmaxillary/transpterygoid approach potentially may obviate the drawbacks associated with open surgery. The anatomy of the parapharyngeal space is complex and critical; therefore, a comparison of the anatomy exposed by these different approaches could aid in the decision making toward a minimally invasive surgical corridor.

STUDY DESIGN

Technical Note.

METHODS

The parapharyngeal space was accessed endonasally by removal of the medial and posterior walls of the maxillary sinus. To allow better visualization and increased triangulation of a bimanual dissection technique, a sublabial canine fossa antrostomy was created. The medial and lateral pterygoid plates were removed. Further lateral dissection exposed the relevant anatomy of the parapharyngeal space. A subtemporal preauricular infratemporal approach was also completed.

RESULTS

The endoscopic approach provided sufficient access to the superior portion of the parapharyngeal space. The open approach also provided adequate access; however, it required a larger surgical window, causing greater injury. A significant advantage of the subtemporal approach is the improved access to the petrous portion of the internal carotid artery. Conversely, the endonasal approach provided improved access to the anterior and medial portions of the superior parapharyngeal space.

CONCLUSION

Endoscopic endonasal access utilizing a transmaxillary/transpterygoid approach provides a sufficient surgical window for tumor extirpation. Utilization of this approach obviates some of the morbidity associated with an open procedure.

LEVEL OF EVIDENCE

5.

What is the Best Route to the Meckel Cave? Anatomical Comparison between the Endoscopic Endonasal Approach and a Lateral Approach

Background Traditionally, a pterional approach is utilized to access the Meckel cave. Depending on the tumor location, extradural dissection of the Gasserian ganglion can be performed. An endoscopic endonasal access could potentially avoid a craniotomy in these cases. Methods We performed an endoscopic endonasal approach as well as a lateral approach to the Meckel cave on six anatomic specimens. To access the Meckel cave endoscopically, a complete sphenoethmoidectomy and maxillary antrostomy followed by a transpterygoid approach was performed. For lateral access, a pterional craniotomy with extradural dissection was performed. Results The endoscopic endonasal approach allowed adequate access to the Gasserian ganglion. All the relevant anatomy was identified without difficulty. Both approaches allowed for a similar exposure, but the endonasal approach avoided brain retraction and improved anteromedial exposure of the Gasserian ganglion. The lateral approach provided improved access posterolaterally and to the superior portion. Conclusion The endoscopic endonasal approach to the Meckel cave is anatomically feasible. The morbidity associated with brain retraction from the open approaches can be avoided. Further understanding of the endoscopic anatomy within this region can facilitate continued advancement in endoscopic endonasal surgery and improvement in the safety and efficacy of these procedures.

Combined transoral and endoscopic approach for total maxillectomy: a pioneering report

Total maxillectomy is sometimes necessary especially for malignant tumors originating from the maxillary sinus. Here we describe a combined transoral and endoscopic approach for total maxillectomy for the treatment of malignant maxillary sinus tumors and evaluate its short-term outcome. This approach was evaluated in terms of the physiological function, aesthetic outcome, and complications. Six patients underwent the above-mentioned approach for resection of malignant maxillary sinus tumors from May 2010 to June 2011. This combined transoral and endoscopic approach includes five basic steps: total sphenoethmoidectomy, sublabial incision, incision of the frontal process of the maxilla, incision of the zygomaticomaxillary fissure, and hard palate osteotomy. All patients with malignant maxillary sinus tumors successfully underwent the planned total endoscopic maxillectomy without the need for facial incision or transfixion of the nasal septum; there were no significant complications. Five patients received preoperative radiation therapy. All patients were well and had no recurrence at follow-up from 13 to 27 months. The combined approach is feasible and can be performed in carefully selected patients. The benefit of the absence of facial incisions or transfixion of the nasal septum, potential improvement in hemostasis, and visual magnification may help to decrease the morbidity of traditional open approaches.

Posterior pedicle lateral nasal wall flap: new reconstructive technique for large defects of the skull base

BACKGROUND

Indications for expanded endoscopic approaches continue to grow, resulting in larger and more complex skull base defects. Reconstructive developments, however, have lagged our extirpative capabilities. As the complexity of clinical scenarios continues to escalate, challenging our current reconstructive strategies, we are compelled to develop alternative techniques to prevent cerebrospinal fluid leaks and protect neurovascular structures. In this article we show the anatomic basis for a new posterior pedicled flap from the lateral wall of the nose (Carrau-Hadad [C-H] flap) for the reconstruction of median skull base defects and present our early clinical experience.

METHODS

Using a cadaveric model, we designed a posterior pedicle flap comprising the nasal inferolateral wall mucoperiosteum. We applied this information clinically, to reconstruct transmural skull base defects.

RESULTS

In our cadaveric model, we harvested and transposed C-H flaps into various defects of the planum sphenoidale, sella turcica, clivus, and nasopharynx. Then, we used the C-H flap in four patients, successfully reconstructing their clival (n = 3) and sellar (n = 1) surgical defects. All patients healed uneventfully.

CONCLUSION

Our anatomic study and early clinical experience support the use of the posterior pedicle lateral nasal wall flap to reconstruct large cranial base defects resulting from endoscopic skull base surgery in properly selected patients.

Endoscopic nasopharyngectomy and its role in managing locally recurrent nasopharyngeal carcinoma

Local recurrence after primary radiation of nasopharyngeal carcinoma (NPC) remains an important cause of morbidity and mortality. Salvage treatment using reirradiation or surgery has been shown to improve survival over nontreatment. Surgery is traditionally performed using an open approach. Advances in endoscopic approaches for resection of paranasal sinus tumors have been extended to NPC. This article reviews the treatment options, in particular the role of endoscopic nasopharyngectomy in the management of recurrent NPC. The endoscopic anatomy, surgical principles, and published results on endoscopic nasopharyngectomy are presented. Short-term outcomes for early-stage recurrences are promising but long-term follow-up is needed.

A case of monocular blindness as the initial presentation of hepatocellular carcinoma with skull metastasis

A 52-year-old man suffering from monocular blindness, with light perception only, was admitted to our hospital. The symptom had begun as low vision and developed rapidly within 3 weeks into monocular blindness in the right eye, with no other systemic manifestations. Imaging examinations revealed multiple hepatocellular carcinomas in the cirrhotic liver, and tumors at the skull base and vertebra. A pathological and immunochemical study of specimens obtained by endoscopic transnasal tumor biopsy and laminectomy revealed them to be metastatic hepatocellular carcinomas (HCCs). Although the patient underwent radiation therapy and chemotherapy, he died 5 months after admission to our hospital. The cranial HCC, involving only the optic canal, may have disturbed the optic nerve in preference to the other cranial nerves. This is the first report of a HCC patient with monocular blindness as the initial presentation of the disease.

Endoscopic resection of sinonasal malignancies

Malignant tumors of the sinonasal tract are rare, accounting for only 1% of all malignancies. Although they are associated with substantial histological heterogeneity, surgery plays a key role in their management. This review addresses the evolution of current treatments in view of the introduction of endoscopic resection techniques. The absence of facial incisions and osteotomies, decreased hospitalization time, better control of bleeding, improved visualization of tumor borders, and reduced morbidity and mortality rate are the major advantages of endoscopic techniques in comparison to traditional external approaches. The major criticisms focus on oncologic results in view of the short/intermediate follow-up of large series, which have commonly grouped together several histologies that may be associated with different prognoses. Since prospective studies contrasting the results of endoscopic and craniofacial resections are difficult to carry out given the rarity of the disease together with ethical issues, the creation of a large database would favor the analysis of several variables related to the patient, tumor, and treatment on survival performed on a large number of patients.

Combined transnasal endoscopic and transoral robotic resection of recurrent nasopharyngeal carcinoma

BACKGROUND

We report a case of resecting a recurrent nasopharyngeal carcinoma using a combined technique of transoral robotic surgery and transnasal endoscopic surgery.

METHOD

A small recurrent tumor was located in the roof of the nasopharynx. The inferior part of the resection was performed with a da Vinci surgical robot transorally after splitting the soft palate to expose the nasopharynx. The superior part of the resection, including removal of the anterior wall and floor of the sphenoid was performed transnasally under endoscopic vision.

RESULTS

The tumor was removed enbloc with the sphenoid sinus wall with clear resection margin. Recovery was uneventful and the patient had minimal morbidity from the operation.

CONCLUSION

For minimally invasive surgery to resect recurrent nasopharyngeal carcinoma, transnasal endoscopic surgery and transoral robotic surgery compliments each other, allowing improved resection.