Comprehensive Management of the Paranasal Sinuses in Patients Undergoing Endoscopic Endonasal Skull Base Surgery.

OBJECTIVE: The endonasal route often provides the most direct and safe approach to skull base pathology. In this article we review the literature with regard to management of the paranasal sinuses in the setting of skull base surgery. METHODS: We describe our institutional experience and review the literature of concurrent management of the sinusitis in patients undergoing endoscopic skull base surgery. RESULTS: Patients should be optimized preoperatively to ensure the endonasal route is a safe corridor to enter the intracranial cavity. Often the paranasal sinuses can be surgically addressed at the same time as endoscopic skull base surgery. We describe the technical details of management of the paranasal sinuses when addressing skull base pathology. CONCLUSIONS: Careful management of the paranasal sinuses throughout the peri-operative course is paramount to optimizing sinonasal function and safety

Outcomes of intraoperative ultrasound for endoscopic endonasal transsphenoidal pituitary surgery in adenomas with parasellar extension

Background: Pituitary adenomas with parasellar extension present a technical challenge for adequate visualization and gross total resection (GTR). The endoscope improves identification of parasellar extension, however, additional intraoperative imaging adjuncts can further augment visualization. Intraoperative ultrasound (iUS) may provide a viable and cost-effective solution for intraoperative imaging. We sought to assess the ability of intraoperative ultrasound to predict extent of resection on 3-month postoperative magnetic resonance imaging (MRI) in pituitary adenomas with parasellar extension. Methods: Twenty consecutive patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary adenomas with the assistance of intraoperative ultrasound were prospectively collected. Intraoperative ultrasound findings were recorded during each case. 3-month postoperative MRI studies were reviewed in a blinded fashion to assess for residual tumor and compared with the intraoperative ultrasound findings. Results: Median preoperative Knosp grade was 2. Cavernous sinus invasion was encountered intraoperatively in 3 patients, all of whom were Knosp grade 3 preoperatively. Median operative time was 152 min. Based on iUS findings, 17 patients were expected to have a GTR while 3 patients underwent subtotal resection. 18 patients completed a 3-month postoperative MRI. The iUS and MRI findings were concordant in 16 cases (88.9%) with only two instances of discordance. Conclusion: Intraoperative ultrasound can reliably predict tumor resection as assessed by 3-month postoperative MRI in pituitary adenomas with parasellar extension. Image capture and interpretation may vary based on operator experience. Ultrasound provides reliable immediate assessment of extent of resection, identification of normal pituitary gland and other important neurovascular structures