Expanded endoscopic endonasal surgery for advanced stage juvenile angiofibromas: a retrospective multi-center study

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The learning curve for endonasal surgery of the cranial base: a systematic approach to training

Proper training in endoscopic endonasal surgery of the cranial base is essential to avoid unnecessary morbidity and mortality. An incremental program for the training of skull base surgeons is described that accounts for complex skull base anatomy, technical difficulty, potential risk of neural and vascular injury, extent of intradural dissection, and type of pathology. There are multiple pathways for training in endoscopic skull base surgery. The most important feature of a training program is the building of team surgical skills.Carl H. Snyderman, Harshita Pant, Amin B. Kassam, Ricardo L. Carrau, Daniel M. Prevedello, Paul A. Gardne

Endoscopic, endonasal decompression of spinal stenosis with myelopathy secondary to cranio-vertebral tuberculosis: Two cases

Background: Tuberculosis can cause extensive osseo-ligamentous destruction at the cranio-vertebral junction, leading to atlanto-axial instability and compression of vital cervico-medullary centres. This may manifest as quadriparesis, bulbar dysfunction and respiratory insufficiency. Aim: We report two patients presenting with spinal stenosis and cord compression secondary to cranio-vertebral tuberculosis, who were successfully decompressed via an endoscopic, endonasal approach. Study design: Two case reports. Methods and results: Both patients were successfully decompressed via an endoscopic, endonasal approach which provided access to the cranio-vertebral junction and upper cervical spine. Conclusion: An endoscopic, endonasal approach is feasible for the surgical management of cranio-vertebral junction stenosis; such an approach minimises surgical trauma to critical structures, reducing post-operative morbidity and the duration of hospital stay

Management of Complications of Endonasal Cranial Base Surgery

Endoscopic endonasal surgery of the cranial base is maximally invasive surgery and poses many of the same risks as traditional skull base approaches. Preliminary data demonstrates that serious complications can be avoided through a strong foundation in endoscopic skull base anatomy, adherence to principles of surgical dissection, and a dedicated surgical team with proper training and experience. Surgical complications may be categorized by severity, location, organ system or tissue type, and time period. Advances in reconstruction have decreased the incidence of CSF leaks to less than 5%. Major complications such as vascular injury are rare and can be managed using endoscopic techniques. Nasal morbidity is acceptable.Snyderman C.H., Pant H., Gardner P.A., Carrau R.L., Prevedello D.M., Kassam A.B

The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract

PubMedID: 10402519Background. Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated. Methods. A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome. Results. Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months. Conclusions. ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens