Endoscopic graduated multiangle, multicorridor resection of juvenile nasopharyngeal angiofibroma: an individualized, tailored, multicorridor skull base approach

Endoscopic surgical management of juvenile nasopharyngeal angiofibroma: Correlating tumour characteristics, risk of hemorrhage, and recurrence

OBJECTIVES

Juvenile nasopharyngeal angiofibroma is an uncommon tumour primarily seen in young males. It is characterized by its vascular nature and aggressive growth pattern, presenting a significant surgical challenge. Endoscopic sinonasal surgery has become the treatment of choice, reducing both morbidity and blood loss, as well as recurrence rates. This study aims to present the clinical characteristics and surgical outcomes of patients with juvenile nasopharyngeal angiofibroma treated exclusively with endoscopic surgery at our centre.

METHODS

A retrospective cohort study was conducted on cases of juvenile nasopharyngeal angiofibroma treated with endoscopic surgery at a single centre between 2013 and 2023.

RESULTS

A total of 21 patients were included in the study, with a mean age of 17.7 years. 57.14 % of the patients presented with an advanced stage (Stage ≥ IIc Radkowsky). The median volume was 79.2 cm3. Pre-surgical embolization was performed in all cases. 7 patients (33.3 %) required blood transfusion. The need for blood transfusion was associated with greater tumour volume (p = 0.0028), intracranial extension (p = 0.025), extension to the infratemporal fossa (p = 0.024), and orbital extension (p = 0.026). There were 2 cases (9.5 %) of tumour recurrence/persistence, both classified as stage IIIb. Tumour persistence/recurrence was more common in patients with intracranial extension (p = 0.045).

CONCLUSION

Exclusive endoscopic resection of these tumours, regardless of volume and extension, does not increase the risk of blood loss or recurrence. Advanced-stage tumours, especially those with intracranial extension, present a higher risk of bleeding and tumour persistence. In these cases, the low morbidity of the endoscopic approach becomes more evident.

Anterior endoscopic sublabial transmaxillary access to middle cranial base lesions

BACKGROUND

Anterior endoscopic access to middle cranial base lesions becomes feasible in the presence of infratemporal fossa (ITF) involvement. Various approaches, including endoscopic endonasal, transoral sublabial, and transorbital methods, have been described for accessing the ITF through a transmaxillary corridor. Among these approaches, endonasal access is the most commonly preferred, while the transorbital approach is a novel technique gaining popularity. The transoral sublabial approach is considered suitable for selected lesions.

METHODS

Patients who underwent the anterior endoscopic transoral/sublabial transmaxillary approach to middle cranial base lesions at a single institute from 2016 to 2023 were included in this retrospective study. Malignant lesions were excluded from the study. The sublabial approach was exclusively performed in all cases, with the exception of one patient who required a combined approach.

RESULTS

The anterior endoscopic transoral sublabial transmaxillary approach to the infratemporal fossa, upper parapharyngeal space, and middle cranial fossa was performed on 14 patients. The underlying conditions for these patients were as follows: trigeminal schwannomas (n = 8), meningiomas (n = 2), juvenile nasopharyngeal angiofibroma, osteochondroma, arachnoid cyst and encephalocele (n = 1 each). Gross total resection was achieved in 11 cases. The most common complication was numbness in the territory of the maxillary and mandibular nerves (n = 4). Two patients needed endoscopic maxillary antrostomy for persistent suppuration. No wound problems or CSF rhinorrhea occurred. The average follow-up time was 26.6 months.

CONCLUSION

The endoscopic sublabial transmaxillary approach provides direct access to the infratemporal fossa and middle cranial base, enhancing the surgical range of maneuverability while sparing the sinonasal cavity. This procedure is safe, less invasive, and could be used as an efficient corridor for the resection of selected infratemporal fossa lesions with or without extension to the middle cranial base and parapharyngeal space.

Extracapsular Dissection With Narrow-Band Imaging Using the Transnasal Endoscopic Tri-port Approach for Extracranial Trigeminal Schwannoma: A Case Report

The pterygopalatine fossa and infratemporal fossa are often approached through an external incision because of their deep facial location, but this can present problems such as facial scarring and deformity. In schwannoma surgery, intraneural dissection is a useful surgical technique for achieving gross total resection while preserving the capsule, including the nerves. For appropriate enucleation and preservation of the functional nerve, it is indispensable to distinguish between the pseudocapsule and the tumor capsule. This case report presents a case of endonasal surgical intervention for an extracranial trigeminal schwannoma employing the tri-port approach and narrow-band imaging.

MRI features of sinonasal tract angiofibroma/juvenile nasopharyngeal angiofibroma: Case series and systematic review

BACKGROUND AND PURPOSE

To comprehensively summarize the radiological characteristics of sinonasal tract angiofibroma (STA) (commonly known as juvenile nasopharyngeal angiofibroma).

METHODS

Forty-four lesions from 41 cases provided by 33 study articles identified through a systematic review and 13 lesions from 13 cases from our institution associated with patients with STA who underwent MRI were included in the review study, carried out by two board-certified experienced radiologists.

RESULTS

The study participants were all male patients with a mean age of 15.6 years at the time of diagnosis. All of them presented with nasal cavity lesions (100%), predominantly in the nasopharynx (98.2%). The sphenopalatine foramen/pterygopalatine fossa was involved in 76.0%, and compressive shift of the posterolateral wall of the maxillary sinus was present in more than half (57.9%). T2-weighted imaging signal intensity was heterogeneous with mixed high and iso intensities as compared to skeletal muscle (100%). T1-weighted imaging showed partial high signal intensity in 61.1% of the cases. Flow void and intense enhancement were present in almost all cases. Cystic/nonenhancement changes on contrast-enhanced MRI were relatively common (40.8%). The mean apparent diffusion coefficient value (2.07 × 10-3  mm2 /second) and some quantitative dynamic contrast-enhanced MRI parameters were high. There was a significant difference in the frequency of residual/recurrent lesions based on the presence of MRI findings of skull base invasion (p = .017) and intracranial extension (p = .003).

CONCLUSIONS

We summarized the MRI findings of STA that can facilitate timely diagnosis and appropriate management.

Anatomic Considerations Guiding Single Versus Multiportal Endoscopic Approaches for Resection of Juvenile Nasopharyngeal Angiofibroma: Cases Series With Graded Multicorridor Resections

BACKGROUND

Juvenile nasopharyngeal angiofibromas (JNAs) are characterized by expansive and destructive growth, often invading the midline/paranasal sinuses, pterygopalatine fossa, and infratemporal fossa and can extend into the orbit, cavernous sinus, or intracranially.

OBJECTIVE

To evaluete the major benefits of the extended endoscopic endonasal approach (EEA) for JNA resection as compared with more traditional and invasive transpalatal and transfacial approaches. When JNAs extend into lateral anatomic compartments, the optimal operative trajectory often requires additional approach strategies or surgical staging.

METHODS

We retrospectively reviewed 8 cases of large JNAs arising in symptomatic adolescent boys (University of Pittsburgh Medical Center Stages II, III, and V) and discuss anatomic and tumor considerations guiding the decision of a pure EEA vs combined EEA and sublabial transmaxillary approach (Caldwell-Luc).

RESULTS

A pure extended EEA was used in 6 JNA cases (UPMC Stages II-III); a multiportal EEA + Caldwell-Luc maxillotomy was used in 2 cases. One of the 2 patients (UPMC Stage V) previously treated with multiportal EEA + Caldwell-Luc maxillotomy underwent staged left temporal/transzygomatic craniotomy, obtaining gross total resection. Seven patients ultimately underwent complete removal without recurrence. One patient with a small residual JNA (UPMC II) underwent stereotactic radiosurgery without progression to date.

CONCLUSION

JNAs with lateral extension into the infratemporal fossa often benefited from additional lateral exposure using a Caldwell-Luc maxillotomy. Cases with significant skull base and/or dural involvement may undergo staged surgical treatment; temporalis + transzygomatic craniotomy is often useful for second-stage approaches for residual tumor in these lateral infratemporal or intracranial regions. SRS should be considered for residual tumor if additional surgery is not warranted.

Contemporary Surgical Management of Juvenile Nasopharyngeal Angiofibroma

Objectives Juvenile nasopharyngeal angiofibromas (JNAs) are uncommon tumors with an evolving treatment paradigm. The objective of this study was to compare our prior experience reported in 2005 with our most contemporary series to compare practice improvements and the impact of expanded endonasal procedures.

Design Retrospective review comparing a contemporary 22 patients with JNA who underwent surgical management between 2005 and 2019, compared with a historical cohort of 65 patients from the same center.

Results The most common presenting symptom was epistaxis (68%). The median maximum tumor diameter was 4.4 cm. All patients underwent preoperative embolization. An endoscopic endonasal approach (EEA) was used in 18 patients (82%), compared with 9% in the series prior to 2005. Gross total resection was achieved in all patients. The median estimated blood loss was 175 and 350 mL for EEA and open (transfacial) cases, respectively. Only two patients (9%) required a blood transfusion compared with 52% on the previous series. The median follow-up was 19 months. The overall recurrence rate was 9% in this series and 24% in the previous series. No patient required radiation therapy in follow-up compared with 3% in our historical cohort.

Conclusion There have been significant changes regarding the management of patients with JNA compared with the previous Mayo Clinic experience. The EEA has become the preferred route over the transfacial approaches to treat JNA in selected patients who do not have intracranial extension. Preoperative embolization has aided in reducing the postoperative transfusion rates.

Endoscopic Endonasal and Transmaxillary Approach for Resection of Juvenile Nasopharyngeal Angiofibroma With Preoperative Embolization in a Child

ABSTRACT

A 13-year-old Japanese boy with a 6-month history of bilateral nasal obstruction and a 3-week history of recurrent epistaxis from the right nose was admitted to our department. Nasal endoscopy revealed a reddish, smooth-walled tumor occupying the right nasal cavity. Computed tomography scan revealed a 3.5 × 4.5 × 7.0-cm heterogeneously enhancing mass involving the right nasal cavity and extending posteriorly to the nasopharynx, and laterally to the pterygopalatine fossa and the medial part of the infratemporal fossa. We diagnosed as juvenile nasopharyngeal angiofibroma with Radkowski classification stage IIC. The internal maxillary and ascending pharyngeal arteries were embolized with polyvinyl alcohol followed by Embosphere using a conventional Seldinger technique. En bloc resection was performed with an endoscopic ipsilateral endonasal and sublabial Caldwell-Luc transmaxillary approach under general anesthesia. As of 3 years postoperatively, no recurrence has been found. We report a child case of juvenile nasopharyngeal angiofibroma successfully treated with less invasive surgery with preoperative embolization.

Combined Anterior Transmaxillary (Caldwell-Luc) With an Endoscopic Endonasal Transpterygoid Approach for Resection of a Large Juvenile Nasopharyngeal Angiofibroma: 2-Dimensional Operative Video

Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular benign tumor that originates in the sphenopalatine foramen and often spreads to adjacent compartments.1 Microsurgical resection with preoperative embolization remains the treatment of choice.2 We present a case of a large JNA involving multiple compartments. The patient is a 20-yr-old male who presented with long-term right nasal congestion. The MRI demonstrated a large enhancing mass that extended from the right nasal cavity and nasopharynx into the right pterygopalatine fossa (PPF), infratemporal fossa (ITF), and parapharyngeal space. Preoperative angiogram for embolization showed a highly vascular tumor with blood supply mainly from the internal maxillary artery and about 10% from a persistent mandibular branch of the internal carotid artery. Based on the UPMC JNA staging system, this tumor was a stage IV.2 A combined anterior transmaxillary (Caldwell-Luc) with an endoscopic endonasal transpterygoid approach was performed. The addition of the anterior transmaxillary approach increases the surgical freedom for traditional bipolar devices and improves the view and trajectory to more lateral structures like the PPF and ITF.3 Gross total resection was achieved without complications. The patient was discharged home with a partial V2 numbness (right superior gum) that improved with time. The endoscopic endonasal approach is a safe and effective technique even for large JNA. A multidisciplinary team consisting of an interventional radiologist, a skull base neurosurgeon, and an otorhinolaryngologist with expertise in endoscopic surgery may play a role for optimal surgical results. The patient consented for the procedure and for the video production.

Pterygovaginal artery as a target of embolization before endoscopic skull base surgery

BACKGROUND

The pterygovaginal artery (PtVA), a recurrent branch of the internal maxillary artery (IMA), can be a feeder of skull base tumors. Preoperative embolization can help endoscopic resection of hypervascular lesions, which is performed under a narrow surgical space with restricted instrumental maneuverability.

METHODS

We performed preoperative embolization in five cases with hypervascular skull base lesions supplied by the PtVA, four of which were resected via endoscopic endonasal approach. In two cases, selective PtVA embolization through the distal IMA was successfully conducted.

RESULTS

In all the cases, intraoperative bleeding during endoscopic resection was easily controlled. The medial and lateral origins of the PtVA from the IMA were demonstrated by cone-beam CT images reconstructed from three-dimensional rotational angiography, and anastomoses around the eustachian tube and soft palate were visualized by superselective angiography.

CONCLUSIONS

The PtVA embolization can be an effective strategy before endoscopic skull base tumor resection. When embolizing through the PtVA, clinicians should be aware of its anatomical variations and dangerous anastomoses. Understanding the surrounding angioarchitecture by angiographic techniques helps ensure safe embolization.

A unique intraluminal growth of juvenile nasopharyngeal angiofibroma: A case report

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, hypervascular, benign tumor which is mainly seen among male adolescents. The tumor typically originates from the sphenopalatine fossa, but could spread through natural foramens and fissures.

There are some reports of atypical growth of this tumor in literature but the intraluminal growth, which could be seen in paraganglioma and glomus tumors, has not reported yet in angiofibroma. In this article we present a case of extensive angiofoibroma with intraluminal involvement of the ophthalmic vein.

Our patient was a 19-year-old boy with a complaint of nasal obstruction and occasional epistaxis since a year ago, without any visual or neurologic complaints. The patient underwent an endoscopic resection of the tumor after embolization via the nasal cavity.

The intraoperative findings revealed the tumor extension to the orbit, intracranial space and cavernous sinus via inferior orbital fissure. The intracranial extension of the tumor was extradural and was successfully excised without CSF leakage. An interesting finding in this patient, was an intraluminal extension of the tumor in to the ophthalmic vein, which was completely excised endoscopically. (pre and post operation pictures are available in the full text). The definitive treatment of angiofibroma is surgical excision. Different surgical approaches are used but nowadays endoscopic resection with or without pre-operative embolization is the first choice of treatment. The intraluminal growth of the tumor was also excised as a pedunculated mass separately.

Juvenile nasopharyngeal angiofibroma-20 years of experience in endoscopic treatment

INTRODUCTION

Juvenile nasopharyngeal angiofibroma is a rare, benign tumor; however, it shows local aggression and leads to profuse nosebleeds. <br/>Aim: The aim of the study is to present 20 years of experience in endoscopic treatment of this tumor. <br/>Material and methods: The material covers 71 patients treated in the years 1985-2019 at the Department of Otolaryngology and Laryngological Oncology in Poznań. In these patients, either the classic external approach, or the double approach - external with the use of endoscopes, or only the endoscopic approach was used. In the entire population, external surgeries were performed in 37 patients, double access in 8 and endoscopic access in 26 patients. <br/>Results: Complete resection of the tumor was achieved in 51 patients (72%). The remaining 20 patients (28%) had a residual or recurrent tumor and all of these patients underwent reoperation.<br/> Conclusions: The endoscopic approach with the use of various optics and navigation allows for the removal of not only small tumors but also much more advanced ones. Pre-operative evaluation of imaging results is extremely important to avoid incomplete tumor removal. Individual development of an operating strategy, a wide range of optics and various surgical methods, and especially endoscopic ones, are the guarantee of therapeutic success.

[Current perspectives on imaging and treatment of juvenile angiofibromas : A review]

CLINICAL ISSUE

Juvenile angiofibroma is a benign tumor, whose surgical treatment may be complicated due to intraoperative hemorrhage. The tumors appear as well circumscribed, reddish masses, which often extend into the complete nasal cavity and nasopharynx.

STANDARD RADIOLOGICAL METHODS

Diagnosis is based on computed tomography (CT) and magnetic resonance imaging (MRI) with angiography to identify supplying blood vessels.

STANDARD TREATMENT

Open resection.

INNOVATION IN TREATMENT

The endoscopic endonasal resection is the therapy of choice and may be combined with open surgery after endovascular embolization. Radiation or hormone therapy are alternatives for patients with very advanced tumors or high surgical morbidity. Depending on location and age of the patients, residual tumors after surgery can be watched only or treated with radiotherapy.

PERFORMANCE

Preoperative endovascular embolization lowers intraoperative blood loss by about 70%, induces tumor shrinkage, and facilitates resection. The endonasal approach will lower the peri- and postoperative morbidity.

RECOMMENDATION

An endonasal approach combined with preoperative endovascular embolization should be preferred over open resection, but requires expertise as well as modern endoscopy and navigation equipment. MRI follow-ups should be performed regularly until after puberty. Recurrence after puberty is very uncommon.

Combined endoscopic and transoral resection of a high-staged juvenile nasopharyngeal angiofibroma: A pictorial essay

Juvenile nasopharyngeal angiofibromas (JNAs) are highly vascular and benign tumors that can expand into the skull base. Delay of treatment can result in intracranial invasion, requiring extensive open approaches such as a facial translocation, maxillary swing, or an orbitozygomatic craniotomy. We describe a single-stage, combined endoscopic and transoral approach on a 14-year-old male with extensive high-stage dumbbell-shaped JNA involving the infratemporal fossa, orbit, buccal space, and intracranial extension into Meckel's cave. Successful resection of the tumor and good postoperative outcome was achieved. A transoral approach allowed for greater access to the infratemporal fossa, where endonasal resection was not possible, allowing for improved visualization, greater traction, and dissection. In select highly staged JNAs with significant lateral extension and intracranial involvement, successful and complete resection may be accomplished with this combined approach. Utilization of this approach avoids the morbidity of more invasive open approaches.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Combined endoscopic endonasal and sublabial transmaxillary approach for resection of giant infratemporal fossa schwannoma with intracranial extension: operative video and technical nuances

Tumors of the infratemporal fossa (ITF) are surgically formidable lesions due to their deep location and proximity to critical neurovascular structures. Selecting the optimal surgical corridor for a giant ITF lesion with extensive medial and lateral extension can be challenging due to the limited surgical freedom offered by each individual approach. In this operative video, we demonstrate a case of a 44-year-old female with a giant ITF schwannoma with intracranial extension and erosion of the central skull base. Although we considered several surgical approaches, including a standard binostril endoscopic endonasal approach and an endoscopic Denker’s approach, we eventually chose a combined endoscopic endonasal and sublabial (Caldwell-Luc) transmaxillary approach. This combined approach provides significantly greater surgical freedom than a pure endonasal route to the lateral ITF. The sublabial Caldwell-Luc corridor provides a more direct “head-on” trajectory to the target of the lateral ITF than the pure endonasal route. This combined approach provides a multiportal, multicorridor access, allowing for more surgical freedom and preservation of the piriform aperture and nasolacrimal duct. This case illustrates the versatility of the combined endoscopic endonasal and sublabial transmaxillary approach for giant ITF tumors with significant lateral extension. The technical nuances and surgical concepts are demonstrated in this operative video manuscript.

The video can be found here: https://youtu.be/gy-pkjLdDgE.

Endoscopic Resection of Pediatric Skull Base Tumors: An Evidence-Based Review

Objectives  To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods  PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results  Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n  = 239) and chondrosarcomas ( n  = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n  = 193, 41.2%) and endoscopic extended transsphenoidal ( n  = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n  = 36, 17.3%) and endocrinopathy ( n  = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion  Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.

Cumulative sum analysis of the learning curve for endoscopic resection of juvenile nasopharyngeal angiofibroma

BACKGROUND

To determine the learning curve with cumulative sum analysis for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and investigate whether the surgeon's expertise is a risk factor for recurrence.

MATERIALS AND METHODS

We reviewed the medical records of patients with JNA who underwent endoscopic or endoscopic-assisted surgery between 2006 and 2015. We used cumulative sum (Cusum) analysis to plot the learning curve for operation time versus chronological sequence, and verified the Cusum curve by risk-adjusted Cusum (RA-Cusum) analysis. We identified three phases of expertise. The recurrence rate was analyzed using the Kaplan-Meier method and log-rank tests. A multivariable Cox regression analysis was performed to identify the independent risk factors for recurrence.

RESULTS

We included 154 JNA patients with a median age of 16 years. The surgeon overcame the learning curve after case 80 with increasing surgical efficiency and competence. The learning curve plotted by Cusum analysis divided the cases into three phases: phase 1, accumulation of initial experience (cases 1-41); phase 2, further accumulation of experience (cases 42-117); and phase 3, mastering the procedure (cases 118-154). Pearson's χ² tests showed that tumor stage (P = 0.021), blood loss (P = 0.001), operation time (P < 0.001), and phase (P < 0.001) were associated with recurrence. The log-rank test showed that time to recurrence was significantly shorter in phase 1 than in phases 2 and 3. Blood loss and phase were independently prognostic factors for time to recurrence, with P values of 0.023 and 0.009, respectively. The RA-Cusum analysis identified two inflection points of the curve at case 44 and 83, and verified the results of Cusum analysis.

CONCLUSION

Surgical experience and competence with endoscopic resection affect the recurrence rate in JNA patients.

LEVEL OF EVIDENCE

4.

Combined Endoscopic and Open Approaches in the Management of Sinonasal and Ventral Skull Base Malignancies

Combined transcranial and endoscopic endonasal approaches remain useful in the treatment of ventral skull base malignancies. The extended bifrontal transbasal approach provides wide access to the anterior ventral skull base and paranasal sinuses without transfacial incisions. In more extensive lesions, the bifrontal transbasal approach can then be combined with an endoscopic endonasal approach (EEA) from below. This article reviews the indications, surgical technique, and operative nuances of combined transbasal and EEA (cranionasal) approaches for the surgical management of ventral skull base malignancies.

Nasal juvenile angiofibroma: Current perspectives with emphasis on management

Juvenile angiofibroma is an uncommon, benign, locally aggressive vascular tumor. It is found almost exclusively in young men. Common presenting symptoms include nasal obstruction and epistaxis. More advanced tumors may present with facial swelling and visual or neurological disturbances. The evaluation of patients with juvenile angiofibroma relies on diagnostic imaging. Preoperative biopsy is not recommended. The mainstay of treatment is resection combined with preoperative embolization. Endoscopic surgery is the approach of choice in early stages, whereas, in advanced stages, open or endoscopic approaches are feasible in expert hands. Postoperative radiotherapy (RT) or stereotactic radiosurgery seem valuable in long-term control of juvenile angiofibroma, particularly those that extend to anatomically critical areas unsuitable for complete resection. Chemotherapy and hormone therapy are ineffective. The purpose of the present review was to update current aspects of knowledge related to this rare and challenging disease. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1033-1045, 2017.

Transnasal endoscopic partial maxillectomy: Operative nuances and proposal for a comprehensive classification system based on 1378 cases

BACKGROUND

Despite the development of functional endoscopic endonasal surgery, there are still areas of the maxillary sinus that remain technically difficult to access using a standard middle meatal antrostomy as well as deep-seated skull base lesions requiring expanded transmaxillary approaches.

METHODS

All patients who underwent transnasal endoscopic partial maxillectomy (TEPM) in a single institution from 2000 to 2014 were retrospectively reviewed. The TEPM was classified into 5 types according to the anatomic structures progressively removed and to the access provided.

RESULTS

The TEPM was performed in 1378 patients for the management of: inflammatory diseases in 513 cases (37%), benign sinonasal tumors in 425 cases (31%), skull base malignancies in 285 cases (21%), and as a corridor to address deep-seated skull base lesions in 155 cases (11%).

CONCLUSION

The TEPM is a stepwise approach offering increasing access that can be tailored to different maxillary, sinonasal, and skull base pathologies with minimal morbidity for patients. © 2016 Wiley Periodicals, Inc. Head Neck 39: 754-766, 2017.

Simultaneous Transventricular-Orbitocranial Resection of Large Suprasellar Craniopharyngioma as Inspired by Jackson's Maneuver from 1863

Traditional skull base techniques utilizing the microscope have allowed surgeons improved safe access to deep-seated lesions. More recent technical advances with the endoscope have allowed improved visibility and access to these previously difficult-to-reach regions. Most current literature emphasizes one technique over the other. We present a unique hybrid-type approach that tackles this not-infrequent surgical dilemma. This hybrid-type surgery resulted in a new technique that is a confluence of both open microsurgery and skull base corridors with an endoscope. Furthermore, a combined ventriculoscope approach adds extended assistance with resection. We detail the utility of this technique.

A patient presented with a large suprasellar lesion that was suspicious for a craniopharyngioma. Given improved survival with extent of resection, the goal of surgical intervention was maximal safe resection. The location of the tumor would have involved certain morbidity with deliberate residual if a skull base approach or endoscope-based approach was employed independently. As a result, the patient underwent a hybrid-type operation using a multi-corridor split-surgical team approach for the resection of her tumor.

The patient underwent hybrid surgery via a combined open microsurgical craniotomy, endoscopic resection, and a ventriculoscope-assisted approach. The ventriculoscope access allowed for resection of the intraventricular portion of the tumor and guided the extent of resection from the microsurgical corridor. Additionally, from a separate craniotomy, the suprasellar component was resected using both standard skull base and endoscope-assisted techniques. The patient tolerated the procedure well without additional morbidity provided from the multi-corridor hybrid technique.

The hybrid surgery resulted in a new multi-modality, split-surgical team approach providing maximal visualization with minimal added morbidity to resect a lesion difficult to access. This hybrid technique may be an effective piece of the surgeon’s armamentarium to provide improved patient outcomes.