Endoscopic cranial base surgery: classification of operative approaches.

OBJECTIVE Endoscopic cranial base surgery is a minimal access, maximally aggressive alternative to traditional transfacial, transcranial, or combined open cranial base approaches. Previous descriptions of endoscopic approaches have used varying terminology, which can be confusing to the new practitioner. Indications for surgery are not well defined. Our objective was to create a comprehensive classification system of the various approaches and describe their indications with case examples. METHODS We prospectively compiled a comprehensive database of our endonasal endoscopic operations, detailing the nasal sinus transgressed, the cranial base approach, and the intracranial target for the first 150 consecutive cases performed at our institution. All cases were performed collaboratively by a neurosurgeon and an otolaryngologist. RESULTS We categorized the endonasal endoscopic cranial base operations into four nasal corridors, nine cranial base approaches, and 13 intracranial targets. Each of the various approaches is described in detail and illustrated with case examples. Pathology encountered included pituitary tumor (50%), meningocele/encephalocele (14%), craniopharyngioma and Rathke cleft cyst (10%), meningioma (8%), chordoma (5%), esthesioneuroblastoma (2%), and other (11%). CONCLUSION Endonasal endoscopic cranial base surgery is a minimal access, maximally invasive alternative to open transcranial cranial base approaches for specific indications. A clear understanding of the possible approaches is facilitated by an awareness of the nasal corridors and intracranial targets.

[1]  H. Jho,et al.  Endoscopic Endonasal Skull Base Surgery: Part 3 - The Clivus and Posterior Fossa , 2004, Minimally invasive neurosurgery : MIN.

[2]  L. Cavallo,et al.  Hemorrhagic vascular complications of endoscopic transsphenoidal surgery. , 2004, Minimally invasive neurosurgery : MIN.

[3]  Manfred Tschabitscher,et al.  Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. , 2005, Neurosurgical focus.

[4]  Jho Hd,et al.  Endoscopic endonasal skull base surgery: Part 3--The clivus and posterior fossa. , 2004 .

[5]  W. Fokkens,et al.  Risk factors for meningitis after transsphenoidal surgery. , 1997, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[6]  D. Locatelli,et al.  Endoscopic endonasal approaches to anterior skull base defects in pediatric patients , 2006, Child's Nervous System.

[7]  Amin Kassam,et al.  Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. , 2007, Journal of neurosurgery.

[8]  H. Jho,et al.  Endoscopic Endonasal Skull Base Surgery: Part 2 - The Cavernous Sinus , 2004, Minimally invasive neurosurgery : MIN.

[9]  F. Esposito,et al.  Endoscopic endonasal transsphenoidal surgery. Before scrubbing in: tips and tricks. , 2007, Surgical neurology.

[10]  L. Cavallo,et al.  Endoscopic Endonasal Transsphenoidal Approach to the Sellar Region , 2003 .

[11]  P. Gardner,et al.  Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. , 2005, Neurosurgical focus.

[12]  C. Cantaroni,et al.  Endoscopic Treatment of Benign Tumors of the Nose and Paranasal Sinuses , 2004, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[13]  H. Jho,et al.  Endoscopic Endonasal Approach to the Ventral Cranio-Cervical Junction: Anatomical Study , 2002, Acta Neurochirurgica.

[14]  Jho Hd,et al.  Endoscopic endonasal skull base surgery: Part 1--The midline anterior fossa skull base. , 2004 .

[15]  E. Pasquini,et al.  Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas. , 2006, Frontiers of hormone research.

[16]  H. Jho,et al.  Endoscopic Endonasal Skull Base Surgery: Part 1 - The Midline Anterior Fossa Skull Base , 2004, Minimally invasive neurosurgery : MIN.

[17]  E. Laws.  Transsphenoidal removal of craniopharyngioma. , 1994, Pediatric neurosurgery.

[18]  O. Hirsch.  ENDONASAL METHOD OF REMOVAL OF HYPOPHYSEAL TUMORSWITH REPORT OF TWO SUCCESSFUL CASES , 1910 .

[19]  L. Sekhar,et al.  The extended frontal approach to tumors of the anterior, middle, and posterior skull base. , 1992, Journal of neurosurgery.

[20]  W Messerklinger,et al.  Background and Evolution of Endoscopic Sinus Surgery , 1994, Ear, nose, & throat journal.

[21]  E. Laws,et al.  Endoscopic transnasal approach to the cavernous sinus versus transcranial route , 2005 .

[22]  H. Jho,et al.  Endoscopic Endonasal Approach to the Pterygopalatine Fossa: Anatomic Study , 2003, Neurosurgery.

[23]  T. Schwartz,et al.  Algorithm for Reconstruction After Endoscopic Pituitary and Skull Base Surgery , 2007, The Laryngoscope.

[24]  P. Gardner,et al.  Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. , 2005, Neurosurgical focus.

[25]  P. Gardner,et al.  The Expanded Endonasal Approach for an Endoscopic Transnasal Clipping and Aneurysmorrhaphy of a Large Vertebral Artery Aneurysm: Technical Case Report , 2006, Neurosurgery.

[26]  J. Lü,et al.  Microsurgical anatomy of Liliequist's membrane. , 2003, Minimally invasive neurosurgery : MIN.

[27]  P. Gardner,et al.  Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. , 2005, Neurosurgical focus.

[28]  H. Stammberger,et al.  Combined endoscopic surgery and radiosurgery as treatment modality for olfactory neuroblastoma (esthesioneuroblastoma) , 2005, Acta Neurochirurgica.

[29]  F. Esposito,et al.  EXTENDED ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL APPROACH FOR THE REMOVALOF SUPRASELLAR TUMORS: PART 2 , 2007, Neurosurgery.

[30]  J. Gilsbach.  Extreme lateral approach to intradural lesions of the cervical spine and foramen magnum. , 1991, Neurosurgery.

[31]  Aldo Cassol Stamm,et al.  Transnasal endoscopic surgical approaches to the clivus. , 2006, Otolaryngologic clinics of North America.

[32]  V. Schramm,et al.  Craniofacial surgery for malignant skull base tumors , 2003, Cancer.

[33]  T. Schwartz,et al.  Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. , 2006, Journal of neurosurgery.

[34]  Ciric Ivan,et al.  Complications of Transsphenoidal Surgery: Results of a National Survey, Review of the Literature, and Personal Experience. , 1997, Neurosurgery.

[35]  C. Snyderman,et al.  A Novel Reconstructive Technique After Endoscopic Expanded Endonasal Approaches: Vascular Pedicle Nasoseptal Flap , 2006, The Laryngoscope.

[36]  P. Battaglia,et al.  Esthesioneuroblastoma: endonasal endoscopic treatment. , 2005, Skull base : official journal of North American Skull Base Society ... [et al.].

[37]  P. Cappabianca,et al.  Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidale & clivus , 2003 .

[38]  E. Laws.  Vascular Complications of Transsphenoidal Surgery , 1999, Pituitary.

[39]  S. Shalet,et al.  Growth Hormone Pulsatility in Acromegaly Following Radiotherapy , 1999, Pituitary.

[40]  P. Gardner,et al.  Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. , 2005, Neurosurgical focus.

[41]  D. Mazzatenta,et al.  Extended transsphenoidal approach [3] (multiple letters) , 2001 .

[42]  Paolo Cappabianca,et al.  Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. , 2002, Journal of neurosurgery.

[43]  H. Jho,et al.  Endoscopic transsphenoidal surgery , 2001, Journal of Neuro-Oncology.

[44]  P. Black,et al.  Incidence and management of complications of transsphenoidal operation for pituitary adenomas. , 1987, Neurosurgery.

[45]  H. Jho,et al.  Endoscopic Endonasal Cavernous Sinus Surgery: An Anatomic Study , 2001, Neurosurgery.

[46]  M. Kaplan,et al.  Complications of Anterior Skull Base Surgery , 1996, Skull base surgery.

[47]  E. Laws,et al.  Transsphenoidal Approaches for the Extracapsular Resection of Midline Suprasellar and Anterior Cranial Base Lesions , 2001, Neurosurgery.

[48]  F. Esposito,et al.  Endoscopic Endonasal Transsphenoidal Approach: Outcome Analysis of 100 Consecutive Procedures , 2002, Minimally invasive neurosurgery : MIN.

[49]  L. Cavallo,et al.  SURGICAL ANATOMY , 2005 .

[50]  W. Couldwell,et al.  Variations on the Standard Transsphenoidal Approach to the Sellar Region, with Emphasis on the Extended Approaches and Parasellar Approaches: Surgical Experience in 105 Cases , 2004, Neurosurgery.

[51]  V. Anand,et al.  Surgical Anatomy and Variations of the Onodi Cell , 1996 .

[52]  H. Cushing.  THE WEIR MITCHELL LECTURE: SURGICAL EXPERIENCES WITH PITUITARY DISORDERS , 1914 .

[53]  F. Doglietto,et al.  The Endoscopic Extended Transsphenoidal Approach for Craniopharyngiomas , 2006, Neurosurgery.

[54]  D. Locatelli,et al.  Endonasal Endoscopic Repair of Sternberg's Canal Cerebrospinal Fluid Leaks , 2007, The Laryngoscope.

[55]  P. Gardner,et al.  Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations. , 2005, Neurosurgical focus.

[56]  F. Esposito,et al.  Anatomical study of the pterygopalatine fossa using an endoscopic endonasal approach: spatial relations and distances between surgical landmarks. , 2007, Journal of neurosurgery.

[57]  H. Stammberger.  The Evolution of Functional Endoscopic Sinus Surgery , 1994, Ear, nose, & throat journal.

[58]  Jho Hd,et al.  Endoscopic endonasal skull base surgery: Part 2--The cavernous sinus. , 2004 .

[59]  P. Gardner,et al.  The Expanded Endonasal Approach: A Fully Endoscopic Transnasal Approach and Resection of the Odontoid Process: Technical Case Report , 2005, Neurosurgery.

[60]  D. Mazzatenta,et al.  Endoscopic treatment of encephaloceles of the lateral wall of the sphenoid sinus. , 2004, Minimally invasive neurosurgery : MIN.

[61]  D. Locatelli,et al.  Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks: Nine-Year Experience , 2006, Neurosurgery.

[62]  L. Cavallo,et al.  The Endoscopic Endonasal Approach to the Lateral Recess of the Sphenoid Sinus via the Pterygopalatine Fossa: Comparison of Endoscopic and Radiological Landmarks , 2006, Neurosurgery.

[63]  J. Leonetti,et al.  Combined Anterior and Anterolateral Approaches to the Cranial Base: Complication Analysis, Avoidance, and Management , 2006, Neurosurgery.

[64]  Acquisition of Surgical Skills for Endonasal Skull Base Surgery: A Training Program , 2007, The Laryngoscope.

[65]  D. Mazzatenta,et al.  Extended transsphenoidal approach. , 2001, Journal of neurosurgery.

[66]  E. Laws,et al.  History of endoscopic skull base surgery: its evolution and current reality. , 2007, Journal of neurosurgery.

[67]  L. Cavallo,et al.  Endoscopic Transsphenoidal Approach: Adaptability of the Procedure to Different Sellar Lesions , 2002, Neurosurgery.

[68]  Felice Esposito,et al.  AVOIDANCE OF CAROTID ARTERY INJURIES IN TRANSSPHENOIDAL SURGERY WITH THE DOPPLER PROBE AND MICRO‐HOOK BLADES , 2007, Neurosurgery.

[69]  F. Esposito,et al.  The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. , 2005, Journal of neurosurgery.