Search

This refers to a case of a patient with an irregular carotid cave aneurysm who presented with new recurrent headaches. She was not eligible for a flow diverting stent as she had chronic menometrorrhagia. An endoscopic endonasal clipping was offered. The patient tolerated the procedure well.By Zachary C. Gersey; Bhuvic Patel; Eric Wang and Georgios A. ZenonosReported by Author; Author; Author; Author [Extracted from the article]

This article evaluates the availability of key information on independent rhinology/skull base surgery fellowship websites compared to the American Rhinologic Society (ARS) website. The study found that out of 37 identified programs, 34 had program-created fellowship websites. On average, program-created websites fulfilled 49.4% of the criteria, while the ARS website fulfilled 58.1%. Important information such as case volume, sample case logs, and graduate placements were inconsistently provided on both types of websites. The article suggests that including these criteria could help applicants make more informed decisions when applying for a fellowship in rhinology/skull base surgery. [Extracted from the article]

This article, titled "Artificial Intelligence in Skull Base Surgery: A Scoping Review," examines the use of artificial intelligence (AI) in the field of skull base surgery. The authors conducted a systematic review of relevant articles published between January 2018 and September 2023. They found that AI is being increasingly utilized in skull base surgery, particularly for diagnostic and prognostic purposes. The majority of the studies focused on radiomics, with MRI being the most common imaging modality used. However, there are still many areas within skull base surgery that have not been explored with AI and warrant further investigation. [Extracted from the article]

The article discusses the versatility of the SPIWAY, an endonasal access guide (EAG) used in surgery. The SPIWAY is a stent that can be placed in the nasal cavity to provide access during endoscopic endonasal surgery. The study includes a retrospective review of cases, a cadaveric model, and a literature review to demonstrate the various uses of the SPIWAY. The article highlights the advantages of the SPIWAY, such as reducing aerosol spread, improving efficiency, and preventing tumor spillage. Overall, the SPIWAY is a useful tool in facilitating access in different surgical approaches within the head and neck. [Extracted from the article]

This article discusses the use of a suction nerve stimulator technique for the resection of pituitary adenomas that invade the cavernous sinus. The cavernous sinus is a complex region with many neurovascular structures, making surgical resection challenging. The study reviewed the cases of 50 patients who underwent the endoscopic endonasal approach for pituitary adenoma resection using the suction nerve stimulator device. The results showed that most patients with preoperative cranial nerve palsy experienced full recovery, and no new postoperative cranial neuropathies were reported. The authors suggest that this technique is safe and valuable in managing pituitary adenomas with cavernous sinus invasion, and further research could establish it as a standard protocol to minimize post-surgical complications. [Extracted from the article]

This article, titled "Immunotherapy in the Management of Sinonasal Mucosal Melanoma: A Systematic Review and Meta-Analysis," provides a comprehensive review of the literature on the use of immunotherapy in the treatment of sinonasal mucosal melanoma (SNMM). The study examines genetic mutations, survival outcomes, and adverse events associated with immunotherapy for SNMM. The review includes 44 studies that met the inclusion criteria, with a total of 876 patients. The findings suggest that adjuvant immune checkpoint inhibitor (ICI) immunotherapy can be effective in select patients with SNMM, particularly those with advanced or metastatic disease. While there is a moderate risk of adverse events, the potential survival benefit outweighs the risks. The study also highlights the need for future research on neoadjuvant immunotherapy in SNMM. [Extracted from the article]

This article examines the relationship between patient age and clinical characteristics and outcomes in endoscopic endonasal surgery (EES) for pediatric skull base neurosurgery. The study analyzes data from a single pediatric center over a 23-year period. The research finds that there are age-dependent differences in pathology, with younger patients more likely to have certain types of tumors and older patients more likely to have others. However, the study concludes that EES can be safely performed in patients of all age ranges, with no significant difference in complication rates. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, discusses the use of the endoscopic endonasal approach (EEA) for the resection of diaphragma sellae meningiomas. The study involved a retrospective review of patients who underwent EEA for the removal of these tumors between 2000 and 2023. The results showed that EEA was successful in achieving gross total resection in the majority of cases, with minimal postoperative complications. The study suggests that EEA is a viable and safe option for managing diaphragma sellae meningiomas, with potential advantages in preserving visual and pituitary function. [Extracted from the article]

This article presents a case series of patients with Tuberculum Sella Meningiomas (TSMs) who underwent endoscopic endonasal resection. TSMs are challenging to diagnose and treat due to their location near critical neurovascular structures and the optic chiasm. The study included 74 patients, predominantly female, with a median age of 56.7 years. The surgical approach resulted in a high rate of gross total resection and improved visual outcomes. However, CSF leak remains a concern, although it has decreased over time. Overall, the endoscopic endonasal approach is considered a safe and effective treatment for TSMs. [Extracted from the article]

This article discusses the use of endoscopic endonasal approaches (EEA) in the management of foramen magnum meningiomas (FMM). FMM is a rare type of intracranial meningioma, and traditional treatment involves transcranial corridors. The study presents the experience of the authors in using EEA for FMM resection and highlights its role and limitations. The results show that EEA can be an alternative corridor for carefully selected patients with ventral FMM, especially when involvement or encasement of the anterior spinal arteries is suspected. However, CSF leak remains a significant limitation. [Extracted from the article]

This article presents a retrospective review of pediatric patients who underwent endoscopic endonasal surgery (EES) for skull base pathologies at a large tertiary pediatric hospital between 1999 and 2022. The study included 243 patients with a median age of 14.2 years, with a male predominance. Various pathologies were treated, including juvenile nasopharyngeal angiofibroma, craniopharyngioma, chordoma, pituitary adenoma, encephalocele, Rathke cleft cyst, and basilar invagination or odontoid pannus. Most patients were treated with EES alone, and the overall rate of postoperative complications was 14%. CSF leak was the most common complication. The study concludes that EES is an effective approach for pediatric skull base pathologies, with lower neurovascular complication rates compared to traditional open approaches. [Extracted from the article]

This article discusses the learning curve and changes in practice patterns for pediatric endoscopic endonasal surgery (EES) over a 23-year period at a single institution. The authors analyzed data from 243 patients with skull base pathologies treated with EES between 1999 and 2022. They found an increase in the proportion of patients with chordoma and a decrease in the proportion with pituitary adenoma. There were also changes in the anatomical locations of the pathologies treated and an increase in the utilization of advanced reconstruction techniques and adjunctive preoperative treatments. Overall, the authors observed minimal increased morbidity despite treating more complex cases. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, presents the findings of a multicenter study on sellar reconstruction techniques after endoscopic transsphenoidal resection of pituitary tumors. The study aimed to identify the most efficient and least morbid surgical approach to sellar reconstruction. The retrospective chart review included 507 patients from 5 participating sites, and variables such as patient demographics, tumor characteristics, reconstruction technique, postoperative CSF leak, and Sino-Nasal Outcome Test (SNOT-22) scores were analyzed. The study found that the effectiveness and morbidity of different sellar reconstruction techniques were comparable, with no significant differences in postoperative complications and SNOT-22 outcomes. Nasoseptal flaps were more commonly used in cases of giant pituitary adenomas and high-flow intraoperative CSF leaks, while mucosal grafts had shorter operating times. The study also reported a low postoperative CSF leak rate in the cohort. [Extracted from the article]

This article explores the use of radiomic feature analysis to predict overall survival and progression-free survival after surgery in patients with skull base chordomas. The study extracted radiomic features from preoperative MRI scans and used unsupervised analysis to identify distinct groups based on these features. The results showed that the radiomic features were able to model overall survival and progression-free survival, and were also associated with genetic markers commonly used in clinical decision-making. The authors suggest that radiomics-based imaging biomarkers could be a noninvasive and cost-effective way to personalize care for patients with skull base chordomas. [Extracted from the article]

This article analyzes the leadership attributes and innovation of the North American Skull Base Society (NASBS) by examining the accomplishments and academic backgrounds of past NASBS presidents. The study found that the NASBS has had 31 presidents, with a majority being otolaryngologists or neurosurgeons. The presidents had an average age of 53.3 years, were all male, and a small percentage were of non-white race. The study also noted a lack of diversity in terms of gender and race among the NASBS presidents. However, the authors predict that this will change in the future as diversity increases in the field of skull base surgery. [Extracted from the article]

This article discusses the use of the vascularized lateral nasal wall flap (LNWF) in endoscopic endonasal surgery (EES) for closure of complex skull base defects. The study presents a 15-year single-institutional experience with the LNWF, focusing on its role in providing durable closure after intradural endoscopic endonasal tumor resection. The LNWF is an axial transposition flap based on the inferior turbinate artery and its branches, and it can be modified to include the nasal floor and nasal septum for reconstruction of large skull base defects. The primary outcomes measured were postoperative flap necrosis and cerebrospinal fluid (CSF) leak. The study found that the LNWF successfully addressed CSF leak in 64% of cases and that postoperative CSF leak occurred in 28.5% of cases with intraoperative leak. The most common adverse outcomes associated with LNWF closures were CSF leak and flap necrosis. Overall, the LNWF is a valuable technique for the treatment of persistent CSF leaks after endonasal surgery. [Extracted from the article]

This article examines the impact of the COVID-19 pandemic on endoscopic pituitary surgery at a pituitary center of excellence. The study compared patients who underwent surgery before the pandemic (January 2015 to March 2020) with those who had surgery during the pandemic (March 2020 to September 2022). The results showed that patients who presented during the pandemic tended to be more frail and have more comorbidities. They were also more likely to have larger adenomas and require additional surgical approaches. Despite these changes, the length of stay and readmission rate remained stable, indicating the safety of the procedure during the pandemic. [Extracted from the article]

This article discusses the outcomes of the endoscopic endonasal approach (EEA) for nonfunctional pituitary adenomas (NFPAs) in elderly patients. The study involved a retrospective review of NFPAs in patients aged 65 and older who underwent EEA between 2007 and 2022 at a single medical center. The results showed that EEA was a safe and effective option for NFPA resection in elderly patients, with high rates of visual recovery postoperatively and acceptable rates of gross total resection (GTR). The study also identified risk factors for progression and subtotal resection, but found no associations between postoperative complications and age or frailty scores. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, compares four transorbital approaches to the skull base: the lateral orbitotomy, the modified orbitozygomatic approach through a palpebral incision, the modified orbitozygomatic approach through an eyebrow incision, and the supraorbital craniotomy through an eyebrow incision. The study used cadaveric dissections to assess the working corridors and map the anatomical points on the cranial base. The article concludes that each approach has its own advantages and limitations, and appropriate case selection is crucial for successful surgical outcomes. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, introduces a novel outcome metric called the 30-day hospitalization ratio (HR) for patients with pituitary adenomas. The metric combines the length of stay and readmission rates within a 30-day period to provide a comprehensive measure of the economic burden of treatment. The study analyzed the clinical records of 468 patients who underwent endoscopic endonasal surgery for pituitary adenoma. Factors associated with a high HR included high preoperative ASA scores, postoperative lumbar drain placement, intradural extension, and employment status. Understanding these risk factors can lead to personalized monitoring and care, ultimately reducing burden and improving outcomes. [Extracted from the article]

Introduction Trigeminal schwannomas (TS) are rare skull base tumors that have been associated with significant neuropathic sequalae for patients. The authors aim to evaluate the clinical features, treatment outcomes, and neuropathic sequelae following endoscopic endonasal approach (EEA) for TS. Methods The study involves a retrospective review of patients who underwent EEA for resection of TS at a single academic institution between 2004 and 2020. Radiographic and clinical data were recorded and analyzed. Results A total of 16 patients were abstracted, with a mean age at the time of surgery of 44 years with a slight female (1.83:1) predominance. Primary preoperative symptomatology included facial pain/neuralgia (n = 5, 31.3%), facial hypoesthesia (n = 4, 25.0%), and headache (n = 4, 25.0%). Following TS resection, patients were found to have facial hypoesthesia (n = 11, 68.8%), neuropathic keratopathy (n = 4, 25.0%), and mastication musculature atrophy (n = 3, 18.8%). Patients with preoperative facial pain/neuralgia (n = 5, 31.3%) were significantly more likely to try adjunctive pain therapies (p = 0.018) as well as seek pain consultation (p = 0.018). Patients with preoperative migraines (n = 2, 12.5%) were significantly more likely to trial adjunctive pain therapies (p = 0.025) and undergo evaluation with pain specialists (p = 0.025). Finally, patients with preoperative pharmacologic agent utilization were significantly more likely to trial adjunctive pain therapies (p = 0.036) and pursue pain consultation (p = 0.036). Conclusion Some degree of trigeminal dysfunction may be more common than previously reported following EEA for TS resection. Factors that appear to play a role in the development of trigeminal dysfunction include pre-existing pain syndromes such as facial pain/neuralgia or headache and preoperative medication utilization. [ABSTRACT FROM AUTHOR]

Objective The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular. Setting/Participants This is a retrospective review of 20 adult patients with SND after EEA for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center. Main Outcome Measures Fifteen measurements related to SND were obtained on pre- and postoperative imaging. Statistical analyses were performed to evaluate differences between pre- and postoperative anatomies. Results The most common EEA was transsellar. Reconstruction techniques included nine free mucosal grafts alone, eight vascularized nasoseptal flaps (NSFs), one combined free mucosal graft/abdominal fat graft, and one combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection, and nasolabial angle postoperatively. Subgroup analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2 mm, p = 0.039) and increased alar base width (1.2 mm, p = 0.046) postoperatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on postoperative imaging, in contrast to those with functional adenomas who had no measurable significant changes. Conclusion Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests. [ABSTRACT FROM AUTHOR]

Introduction  The application of cranial tissue sealants to assist with postoperative closure is widespread, but data are lacking regarding its utility in endoscopic endonasal surgery (EEA). A prospective study was conducted to assess the effect of sealant usage on postoperative cerebrospinal fluid (CSF) leak rate following standard reconstruction. Methods  A prospective trial of sealant usage after endoscopic endonasal skull base surgery was performed from May 2016 to June 2019 at a tertiary referral cranial base center. This study enrolled 300 consecutive adult and pediatric patients with skull base pathology who underwent EES in which an intraoperative CSF leak occurred. Patients were sequentially stratified into equally sized groups who did or did not receive sealant as part of their reconstruction. Results  Three hundred consecutive adult and pediatric patients were enrolled in the study and had a confirmed intraoperative CSF leak. The intervention cohort with sealant (first 150 patients) had 21 postoperative CSF leaks (14% rate) compared with 9 postoperative CSF leaks (6% rate) in the control group without sealant (p  = 0.02). On multivariate analysis, sealant usage was associated with a higher rate of postoperative CSF leak (odds ratio [OR] = 2.7; p  = 0.025). Male gender (OR = 2.4; p  = 0.04) and high-flow intraoperative CSF leak (OR = 3.1; p  = 0.038) were also found to be associated with postoperative CSF leak. Conclusion  Among all patients undergoing EES with an intraoperative CSF leak, the addition of sealant to standard closure techniques did not reduce the rate of postoperative CSF leaks. [ABSTRACT FROM AUTHOR]

Objective  The jugular foramen is one of the most challenging surgical regions in skull base surgery. With the development of endoscopic techniques, the endoscopic endonasal approach (EEA) has been undertaken to treat some lesions in this area independently or combined with open approaches. The purpose of the current study is to describe the anatomical steps and landmarks for the EEA to the jugular foramen and to compare it with the degree of exposure obtained with the lateral infratemporal fossa approach. Materials and Methods  A total of 15 osseous structures related to the jugular foramen were measured in 33 adult dry skulls. Three silicone-injected adult cadaveric heads (six sides) were dissected for EEA and three heads (six sides) were used for a lateral infratemporal fossa approach (Fisch type A). The jugular foramen was exposed, relevant landmarks were demonstrated, and the distances between relevant landmarks and the jugular foramen were obtained. High-quality pictures were obtained. Results  The jugular foramen was accessed in all dissections by using either approach. Important anatomical landmarks for EEA include internal carotid artery (ICA), petroclival fissure, inferior petrosal sinus, jugular tubercle, and hypoglossal canal. The EEA exposed the anterior and medial parts of the jugular foramen, while the lateral infratemporal fossa approach (Fisch type A) exposed the lateral and posterior parts of the jugular foramen. With EEA, dissection and transposition of the facial nerve was avoided, but the upper parapharyngeal and paraclival ICA may need to be mobilized to adequately expose the jugular foramen. Conclusion  The EEA to the jugular foramen is anatomically feasible but requires mobilization of the ICA to provide access to the anterior and medial aspects of the jugular foramen. The lateral infratemporal approach requires facial nerve transposition to provide access to the lateral and posterior parts of the jugular foramen. A deep understanding of the complex anatomy of this region is paramount for safe and effective surgery of the jugular foramen. Both techniques may be complementary considering the different regions of the jugular foramen accessed with each approach. [ABSTRACT FROM AUTHOR]

Background  High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks. Objective  This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair. Methods  Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors. Results  Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) (p  = 0.02). All patients with a persistent CSF leak developed meningitis (p  = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair. Conclusion  Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial–pericranial flaps, should be considered as an early rescue option in obese patients. [ABSTRACT FROM AUTHOR]

Objective  Though microvascular free tissue transfer is well established for open skull base reconstruction, normative data regarding flap design and inset after endoscopic endonasal skull base surgery (ESBS) is lacking. We aim to describe anatomical considerations of endoscopic endonasal inset of free tissue transfer of transclival (TC) and anterior cranial base resection (ACBR) defects. Design and Setting  Radial forearm free tissue transfer (RFFTT) model. Participants  Six cadaveric specimens. Main Outcome Measures  Pedicle orientation, pedicle length, and recipient vessel intraluminal diameter. Results  TC and ACBR defects averaged 17.2 and 11.7 cm 2 , respectively. Anterior and lateral maxillotomies and endoscopic medial maxillectomies were prepared as corridors for flap and pedicle passage. Premasseteric space tunnels were created for pedicle tunneling to recipient facial vessels. For TC defects, the RFFTT pedicle was oriented cranially with the flap placed against the clival defect (mean pedicle length 13.1 ± 0.6 cm). For ACBR defects, the RFFTT pedicle was examined in three orientations with respect to anterior–posterior axis of the RFFTT: anteriorly, posteriorly, and laterally. Lateral orientation offered the shortest average pedicle length required for anastomosis in the neck (11.6 ± 1.29 cm), followed by posterior (13.4 ± 0.7cm) and anterior orientations (14.4 ± 1.1cm) (p  < 0.00001, analysis of variance). Conclusions  In ACBR reconstruction using RFFTT, our data suggests lateral pedicle orientation shortens the length required to safely anastomose facial vessels and protects the frontal sinus outflow anteriorly while limiting pedicle exposure through a maxillary corridor within the nasal cavity. With greater understanding of anatomical factors related to successful preoperative flap planning, free tissue transfer may be added to the ESBS reconstruction ladder. [ABSTRACT FROM AUTHOR]

Intraoperative cerebrospinal fluid (CSF) leaks are associated with increased risk of postoperative CSF leaks despite multilayered reconstruction with vascularized tissue. A recent randomized controlled trial (RCT) examining the use of perioperative lumbar drains (LD) in high-risk skull base defects identified a significant reduction in postoperative CSF leak incidence (21.2 vs. 8.2%; p  = 0.017). This study was conducted to assess the efficacy of the selective use of CSF diversion, for patients with intraoperative CSF leaks involving endoscopic endonasal approaches (EEA) to the skull base. Method  Consecutive endoscopic endonasal surgeries of the skull base from a pre-RCT cohort and post-RCT cohort were compared. The following case characteristics between the two cohorts were examined: patient age, body mass index (BMI), rate of revision surgery, tumor histology, use of CSF diversion, and vascularized reconstruction. The primary measured outcome was postoperative CSF leak. Results  The pre-RCT cohort included 76 patients and the post-RCT cohort included 77 patients, with dural defects in either the anterior or posterior cranial fossa (pituitary and parasellar/suprasellar surgeries excluded). There was a significant reduction in the incidence of postoperative CSF leak in the post-RCT cohort (27.6 vs. 12.9%; p  = 0.04). On subgroup analysis, there was a trend toward improvement in CSF leak rate of the anterior cranial fossa (19.2 vs. 10.5%; p  = 0.27), whereas CSF leak rates of the posterior cranial fossa were significantly reduced compared with the pre-RCT cohort (41.4 vs. 12.8%; p  = 0.02). Conclusion  This study demonstrates that the integration of selective CSF diversion into the reconstructive algorithm improved postoperative CSF leak rates. [ABSTRACT FROM AUTHOR]

Objectives  This study aimed to establish the anatomical landmarks for performing a contralateral transmaxillary approach (CTM) to the petrous apex (PA) and petroclival region (PCR), and to compare CTM with a purely endoscopic endonasal approach (EEA). Design  EEA and CTM to the PA and PCR were performed bilaterally in eight human anatomical specimens. Surgical techniques and anatomical landmarks were described, and EEA was compared with CTM with respect to ability to reach the contralateral internal acoustic canal (IAC). Computed tomographic scans of 25 cadaveric heads were analyzed and the "angle" and "reach" of CTM and EEA were measured. Results  Entry to the PA via a medial approach was limited by (1) abducens nerve superiorly, (2) internal carotid artery (ICA) laterally, and (3) petroclival synchondrosis inferiorly (Gardner's triangle). With CTM, it was possible to reach the contralateral IAC bilaterally in all specimens dissected, without dissection of the ipsilateral ICAs, pterygopalatine fossae, and Eustachian tubes. Without CTM, reaching the contralateral IAC was possible only if: (1) angled endoscopes and instruments were employed or (2) the pterygopalatine fossa was dissected with mobilization of the ICA and resection of the Eustachian tube. The average "angle" and "reach" advantages for CTM were 25.6-degree greater angle of approach behind the petrous ICA and 1.4-cm more lateral reach. Conclusion  The techniques and anatomical landmarks for CTM to the PA and PCR are described. Compared with a purely EEA, the CTM provides significant "angle" and "reach" advantages for the PA and PCR. [ABSTRACT FROM AUTHOR]

Objective  Previous work categorized skull base chordoma (SBC) into three genetic risk groups based on 1p36 and homozygous 9p21(p16) deletions, accounting for a wide variability in prognosis (A = low-risk, B = intermediate-risk, C = high-risk). However, it remains unclear how these groups could guide management. Study Design  By integrating surgical outcome and adjuvant radiation (AdjXRT) information with genetic data on 152 tumors, we sought to develop an evidence-based management algorithm for SBC. Results  Gross total resections (GTRs) were associated with improved progression free survival (PFS) in all genetic groups. For Group C tumors, GTR and AdjXRT independently contributed to PFS (multivariate Cox proportional hazard ratio [HR] = 0.14, p  = 0.002, and HR = 0.40, p  = 0.047, respectively). For Group B tumors, AdjXRT improved outcomes only when GTR was not feasible (log-rank p  = 0.008), but not following GTR (log-rank p  = 0.54). However, 24 of 25 Group A tumors underwent GTR, and AdjXRT for these did not confer any benefit (log-Rank p  = 0.285). The high GTR rates in Group A could be explained by smaller tumor sizes (mean = 0.98cc/4.08cc/4.92cc for Group A/B/C, respectively, p  = 0.031) and lack of invasiveness. Group A tumors were also more frequently diagnosed in young people (p  = 0.002) as asymptomatic lesions (p  = 0.001), suggesting that they could be precursors to tumors in higher risk groups. Conclusion  Genotypic grouping by 1p36 and homozygous 9p21(p16) deletions can predict prognosis in SBC and guide management. GTR remains the cornerstone of SBC treatment and can be sufficient without AdjXRT in low and intermediate risk tumors. Low-risk tumors are associated with a less invasive phenotype, which makes them more amenable to GTR. [ABSTRACT FROM AUTHOR]

Background  A nasal access guide (NAG) for endoscopic endonasal approaches (EEAs) to the skull-base has been developed and approved for clinical use but its utility has not been formally investigated. Objective  The study aims to assess the effect of a NAG on endoscopic visualization during cadaveric dissection and to perform a workflow analysis with process-based performance measures in the operating room and their effect on clinical outcomes. Methods  Skull-base course participants were observed during hands-on cadaveric dissection with and without NAG. Instances of endoscope withdrawal for lens cleaning and inadequate visualization due to lens soiling were tabulated. Participants completed a Likert-scale survey examining the NAG utility and provided an overall grading. Surgical workflow and process-based performance on patients undergoing EEA to the skull-base was analyzed. Passage of powered and dissecting instruments, removal of endoscopes for cleaning, and dislodgment or migration of the device were reviewed. Postoperative assessments included mucosal trauma and synechiae formation. Results  Instances of endoscope soiling and manual cleaning were significantly reduced by 40% and 61% with the NAG during cadaveric dissection. The overall grading of the device was 2.75/3. Surgical workflow was observed in 35 patients. Average number of passes of endoscopes, instruments, and powered tools during a 10-minute observation period were 3,17, and 5 during the surgical approach, and 3, 18, and 1 during tumor dissection. Dislodgement of the device occurred in 25.7% and migration of the device in 2.8% of cases. Postoperative synechiae, exposed cartilage or septal perforation was not observed in follow up. Conclusion  NAG can significantly reduce inadequate visualization during EEA to the skull-base and has the potential to reduce instances of nasal trauma. Participants assessed its overall utility as being "excellent." [ABSTRACT FROM AUTHOR]

Objectives  The incidence of seizures following a craniotomy for tumor removal varies between 15 and 20%. There has been increased use of endoscopic endonasal approaches (EEAs) for a variety of intracranial lesions due to its more direct approach to these pathologies. However, the incidence of postoperative seizures in this population is not well described. Methods  This is a single-center, retrospective review of consecutive patients undergoing EEA or open craniotomy for resection of a cranial base tumor between July 2007 and June 2014. Patients were included if they underwent an EEA for an intradural skull base lesion. Positive cases were defined by electroencephalograms and clinical findings. Patients who underwent a craniotomy to remove extra-axial skull base tumors were analyzed in the same fashion. Results  Of the 577 patients treated with an EEA for intradural tumors, 4 experienced a postoperative seizure (incidence 0.7%, 95% confidence interval [CI]: 0.002–0.02). Over the same period, 481 patients underwent a craniotomy for a skull base lesion of which 27 (5.3%, 95% CI: 0.03–0.08) experienced a seizure after surgery. The odds ratio for EEA was 0.13 (95% CI: 0.05–0.35). Both populations were different in terms of age, gender, tumor histology, and location. Conclusion  This study is the largest series looking at seizure incidence after EEA for intracranial lesions. Seizures are a rare occurrence following uncomplicated endonasal approaches. This must be tempered by selection bias, as there are inherent differences in which patients are treated with either approach that influence the likelihood of seizures. [ABSTRACT FROM AUTHOR]

Endoscopic endonasal approaches offer an important alternative in the management of posterior inferomedial orbital pathology. Beginning with endoscopic orbital decompressions for Graves' disease, the endonasal corridor for the management of intra- and extraconal pathologies has continued to evolve. Endonasal removal of orbital cavernous hemangiomas is well described in the literature; however, many other benign and malignant pathologies of the medial orbit can be accessed through this approach. Advantages of the endonasal approach include improved visualization and decreased manipulation of orbital contents in the medial and posterior orbit. Additionally, for tumors that extend from the paranasal sinuses into the orbit, this corridor may be ideal for concurrent management. The current literature for this approach will be reviewed including the oncologic results, complications, limitations, and reconstructive needs along with pertinent anatomy. In addition, data from our own institution will be reviewed. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to review endoscopic skull base surgeon experience with internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) to provide an estimate of the incidence of ICA injury, the associated factors and identify the best training modalities for the management of this complication. Design Anonymous electronic survey of past participants at a well-established endoscopic skull base surgery course and a global online community of skull base surgeons. Main Outcome Measures Relative incidence of ICA injuries during EES, associated anatomic and intraoperative factors, and surgeon experience. Results At least 20% of surgeons in each surveyed population experienced a carotid artery injury. Reported carotid artery injuries were most common during tumor exposure and removal (48%). The parasellar carotid artery was the most commonly injured segment (39%). Carotid artery injuries were more common in high-volume surgeons, but only statistically significant in one of the two populations. Attendance at a skull base course or courses did not change the incidence of carotid artery injury in either surveyed population. In both surveys, respondents preferred live surgeries or active (not computer simulated) training models. Conclusions ICA injury is underreported and most common when manipulating the parasellar carotid artery for exposure and tumor dissection. Given the high morbidity and mortality associated with these injuries, vascular injurymanagement should be prioritized and taught in a graduated approach by modern endoscopic skull base courses. [ABSTRACT FROM AUTHOR]

Background We evaluated a transrectus capitis posteriormuscle triangle approach to the posterolateral foramen magnum, occipital condyles, jugular tubercle, and the fourth ventricle. We also assessed factors that affect the amount of bone removal required. Objective To evaluate if the proposed approach is as effective as standard open approaches to expose the lateral portion of the foramen magnum. Methods The proposed minimally invasive fully endoscopic approach was performed in 15 cadaveric specimens using 4-mm (0- and 45-degree) endoscopes. Results Using a 5-cm straight paramedian incision, the rectus capitis posterior minor and major muscles were partially removed unilaterally, providing a corridor through the muscles to reach the foramen magnum region. After meticulous soft tissue dissection, key anatomical landmarks can be identified such as the greater occipital nerve, the vertebral artery that wraps around the atlanto-occipital joint, and the bony protuberance that heralds the occipital condyle. A suboccipital craniotomy associated with the transcondylar, supracondylar or paracondylar approach is performed depending on the amount of bone removal desired to maximize the surgical view. By doing so, the jugular foramen can be exposed laterally as well as the fourth ventricle medially. Conclusion The proposed endoscopic approach can provide access through the transrectus capitis posterior muscle triangle leading directly to the occipital condyle. A stepwise approach is critical to gain a surgical corridor to the inferolateral petroclival region and the fourth ventricle. [ABSTRACT FROM AUTHOR]

Objective To evaluate visual outcomes and potential complications for optic nerve decompression using an endoscopic endonasal approach (EEA) for fibrous dysplasia. Design Retrospective chart review of patients with fibrous dysplasia causing extrinsic compression of the canalicular segment of the optic nerve that underwent an endoscopic endonasal optic nerve decompression at the University of Pittsburgh Medical Center from 2010 to 2013. Main Outcome Measures The primary outcome measure assessed was best-corrected visual acuity (BCVA) with secondary outcomes, including visual field testing, color vision, and complications associated with the intervention. Results A total of four patients and five optic nerves were decompressed via an EEA. All patients were symptomatic preoperatively and had objective findings compatible with compressive optic neuropathy: decreased visual acuity was noted preoperatively in three patients while the remaining patient demonstrated an afferent pupillary defect. BCVA improved in all patients postoperatively. No major complications were identified. Conclusion EEA for optic nerve decompression appears to be a safe and effective treatment for patients with compressive optic neuropathy secondary to fibrous dysplasia. Further studies are required to identify selection criteria for an open versus an endoscopic approach. [ABSTRACT FROM AUTHOR]

Objectives To identify the prevalence and risk factors for nasal deformities after endoscopic endonasal surgery (EES) of the skull base. Design Retrospective case series. Setting Tertiary referral academic center. Participants EES patients from January 2011 to October 2013. Main Outcome Measures Surgical approach, method of skull base reconstruction, and postoperative nasal deformities. Results Of 328 patients, 19 patients (5.8%) had nasal dorsum collapse, 3 (0.9%) with new septal perforations and 2 (0.6%) with septal deviations requiring surgical correction. Postoperative deformities were only found in the setting of nasoseptal flap reconstruction (p = 0.0001) and were most common in patients who had undergone an approach involving more than one anatomical subsite (p = 0.0021). Patients with nasal deformities were on average 6 years younger (p = 0.08) and were more likely to have a malignant pathology (p = 0.08). Conclusions All deformities were associated with use of a nasoseptal flap for reconstruction and were most common in combined approaches, suggesting that flap size may play a role in the development of nasal deformities. The mechanism of nasal dorsum collapse is unclear but does not appear to be related to septal cartilage necrosis. These findings warrant a prospective analysis to identify risk factors for postoperative nasal deformities and data for counseling of patients. [ABSTRACT FROM AUTHOR]

Objective The lack of a standard technique may be a relevant issue in teaching endoscopic endonasal surgery (EES) to novice surgeons. The objective of this article is to compare different endoscope positioning and microsurgical dissection techniques in EES training. Methods A comparative trial was designed to evaluate three techniques: group A, one surgeon performing binarial two-hands dissection using an endoscope holder (rigid endoscopy); group B, two surgeons performing a combined binarial two- and threehanded dissection with one surgeon guiding the endoscope (dynamic endoscopy); and group C, two surgeons performing a binarial two-hands dissection with one surgeon dedicated to endoscope positioning and the other dedicated to a two-handed dissection. Trainees were randomly assigned to these groups and oriented to complete surgical tasks in a validated training model for EES. A global rating scale, and a specifictask checklist for EES were used to assess surgical skills. Results The mean scores of the global rating scale and the specific-task checklist were higher (p = 0.001 and 0.002, respectively) for group C, reflecting the positive impact of dynamic endoscopy and bimanual dissection on training performance. Conclusions We found that dynamic endoscopic and bimanual-binarial microdissection techniques had a significant positive impact on EES training. [ABSTRACT FROM AUTHOR]