Skull Base Volume 12 Month. Patients. Anterior/Midline. Pituitary CSF Leak. Lateral. Craniocervical Junction

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UC SF 2 11/7/2009 Skull Base Surgery in 2009 Ivan El-Sayed MD,

Surgery Program Department Otolaryngology-Head and Neck Surgery

Base Team at UCSF OHNS Ivan El-Sayed, M.D. Andrew Goldberg, M.D. Steve Pletcher, M.

D. Background: Craniofacial Resection 1963 Ketcham presents first

Entire Skull Base through multiple Approaches Skull Base Region

1 UC SF 2 11/7/2009 Skull Base Surgery in 2009 Ivan El-Sayed MD, FACS Director- Otolaryngology Minimally Invasive Skull Base Surgery Program Department Otolaryngology-Head and Neck Surgery University of California-San Francisco Minimally Invasive Skull Base Team at UCSF OHNS Ivan El-Sayed, M.D. Andrew Goldberg, M.D. Steve Pletcher, M.D. Neurosurgery Manish Aghi, M.D. Michael McDermott, M.D. Andrew Parsa, M.D. Background: Craniofacial Resection 1963 Ketcham presents first series of craniofacial resection Open Approaches in 2009 Access Entire Skull Base through multiple Approaches Skull Base Region Anterior Central Antero-Lateral Posterior Approaches Overlap 3 4 1

2 Impact of Endoscopic Technology on Skull Base Surgery at UCSF 2008 Skull Base Volume 12 Month Evolution of Endoscopic Skull Base Surgery Tumor Resection Initially Sella Lesions Patients Anterior/Midline 43 Lateral Craniocervical Junction Pituitary CSF Leak Expanded endoscopic approach Anterior Central Lateral Jho HD Minim Invasive Neurosurg Feb;47(1):1-8. Kassam, Snyderman, Carrau. Expanded Endonasal Approach. Skull Base, vol 14, Supp 1 Feb 2004 Excludes Single Surgeon Pituitary (N=~140) 5 6 Advantages of Endoscopic Surgery Less Morbidity Better Cosmesis Less Brain Retraction Better View than Microscope Endoscope Light is divergent at the tip Can see around corners Key Factors Allowing for Endoscopic Skull Base Surgery Techniques Two surgeon surgery Anatomic approaches by skull base zone Technology Instruments Image Guidance 7 8 2

Two Surgeon Corridor Surgery Principles of Endoscopic Tumor Resection Maintain

Wide Working Corridor Two Surgeon Technique four hands Extracapsular dissection

Corridor (rhinologist, look away) Total Ethmoidectomy Raise Nasal Septal Flap

3 Two Surgeon Corridor Surgery Principles of Endoscopic Tumor Resection Maintain View No scope holder Tumor Dissection Debulking = NOT en bloc Maintain Control Wide Working Corridor Two Surgeon Technique four hands Extracapsular dissection for Malignancy Final Surgical Margin is Equal to Open Approach 9 10 Create Corridor (rhinologist, look away) Total Ethmoidectomy Raise Nasal Septal Flap First for Closure Later Middle Turbinate Resection Open up maxillary sinus Define orbit to orbit in sphenoid. Posterior septectomy or septal incision Allows working room for instruments. B. Hahn El-Sayed et al, Skull Base Journal,

4 Corridors: Trans-sellarsellar Corridors: Trans-planum Corridors: Trans-cribiform Corridors: Trans-clival

Sphenoid Sella/Pituitary Clivus Drill Out Sphenoid Floor Sella Optic Nerves

5 Cranio Cervical Junction Endo-Nasal Endo-Oral Lateral Corridor Maxillary Sinus & Infratemporal Fossa Central Skull Base Central Skull Base Exposure Sphenoid Sella/Pituitary Clivus Drill Out Sphenoid Floor Sella Optic Nerves Carotid Clivus CADAVER DISSECTION Odontoid 19 Kassam et al Neurosurg Focus

6 CSB Optic Nerve Decompression Transplanum Drain Supra-Sellar Sellar Cyst Fibrous Dysplasia Petro-Clival Lesion: Marsupulize Cholesterol Granuloma Nasal Cavity and Anterior Skull Base Lesions of Olfactory Cleft Ethmoid Nasal Cavity

7 Approach to Anterior Skull Base Create Corridor/Tumor Removal Open frontal sinus (Lothrop) Control ethmoid arteries Drill out skull base roof. Elevate cribiform/crista Galli Transect dura/falx Anterior Skull Base: Key Steps Create Corridor Open Frontal Sinus (anterior margin) Debulk Tumor Ligate blood supply Open Frontal Sinus Variable anatomy of the floor Expose Skull Base Open frontal sinus A thick beak of bone may obstruct access Ethmoid cells obstruct the floor

8 Control Ethmoid Arteries Expose Anterior Skull Base Dura Resect Cribiform Resect Dura Dissect out lamina Ethmoids encased in bone Periorbita is margin Closure Nasal Septal Flap Closure: Nasal Septal Flap CSF Leak Rate without vascularized tissue ~20% CSF with NSF: ~5% UCSF technique Duragen Inlay Fat Septal Flap 31 El-Sayed et al, Skull Base

Defect Location 6 1 CSB CSB + NP Location 4 ITF

Skull Base 2008 1 Orbit Number Patients 8 6 4 2

8-9cm 9-10cm Size Defect (cm 2 ) Overall Defect

86cm 2 CSF Leak 0% (N=20) Dural Defect 10-11cm

Skull Base 2008 UC SF UC SF 33 34 ASB Case:

9 Location of Lesion 10 Defect Size No. Patients ACF 3 ACF+ CSB Defect Location 6 1 CSB CSB + NP Location 4 ITF alone 5 ITF +CSB El-Sayed et al. Skull Base Orbit Number Patients <1 1-2cm 2-3cm 3-4cm 4-5cm 5-6cm 6-7cm 7-8cm 8-9cm 9-10cm Size Defect (cm 2 ) Overall Defect Mean Defect Size: 4.95cm 2 Mean Dural Defect: 1.86cm 2 CSF Leak 0% (N=20) Dural Defect 10-11cm 11- >12cm 12cm El-Sayed et al. Skull Base 2008 UC SF UC SF ASB Case: Intracranial Invasion ENB Esthesioneuroblastoma Tumor Fat Graft Post Op Day 1 35 PREOP 3mo POSTOP 36 9

Unilateral ASB Resection: Spare Olfaction

Anterior Extension in Frontal Sinus: SCCA of

Preserved Olfaction 4 years NED Endoscopic

37 38 Post OP: SCCA Ethmoid Lateral Skull Base

10 Unilateral ASB Resection: Spare Olfaction Kadish A Esthesio of Superior Turbinate. Anterior Extension in Frontal Sinus: SCCA of Ethmoid Olfactory Bulb and Dura Resected Preserved Olfaction 4 years NED Endoscopic ASSISTED: Lynch Incision for anterior component. Extended to Eyelid and Involved Frontal Sinus Post OP: SCCA Ethmoid Lateral Skull Base Background Optimal approaches to lateral skull base lesions are still being defined. Fat Graft 22 month NED

Define Lateral Skull Base Maxillary Sinus Pterygoid Fossa Deep Infratemporal Fossa Prior Described Endoscopic Approaches Transeptal Incision Robinson, Wormald Layngoscope 2005 Endo-Assisted Caldwel

11 Define Lateral Skull Base Maxillary Sinus Pterygoid Fossa Deep Infratemporal Fossa Prior Described Endoscopic Approaches Transeptal Incision Robinson, Wormald Layngoscope 2005 Endo-Assisted Caldwel Luc Luc, Har el, AJR 2006 Wormald, Laryngoscope Limitations of PURE Trans-septal septal Incision and Caldwel Luc The piriform aperture- septal window Limits working room Limits angulation Difficult to Coordinate Instrument Endoscopic Anterior Maxillotomy EAM Remove nasofrontal bar at piriform aperture Anterior maxillary wall as needed Entire medial maxillary wall

Endoscopic Anterior Maxillotomy When is EAM Useful?

corridor surgery Anterior Lateral Posterior Lateral Four

visualization 45 46 Procedure: Anterior Incision Anterior

Superior and Inferior to the Inferior Turbinate Drill out

12 Endoscopic Anterior Maxillotomy When is EAM Useful? Improves lateral access and working room Principle of corridor surgery Anterior Lateral Posterior Lateral Four hands - large instruments Allows vascular control and visualization Procedure: Anterior Incision Anterior Maxillotomy Incise Anterior to the Inferior Turbinate Incise Superior and Inferior to the Inferior Turbinate Drill out nasal frontal bar Remove medial maxillary wall. Remove anterior wall up to canine fossa

Address Posterior Maxillary Sinus Eggshell Intact

wall Resect with cloward ronguer Access ptergyoid

Precoagulate tissue and cut Bony landmarks-

planes 50 Have Ability to Control Blood Vessels:

2006-20082008 16 14 12 10 8 6 4 2 0 EAM Endo Endo

Lesions (50% malignant) 16 patients with EAM 3

13 Address Posterior Maxillary Sinus Eggshell Intact Bone Lesion Dissection Drill posterior maxillary wall Resect with cloward ronguer Access ptergyoid contents 49 Locate plane of normal tissue Dissect Precoagulate tissue and cut Bony landmarks- pterygoid plates- mandible Identify soft tissue planes 50 Have Ability to Control Blood Vessels: Internal Maxillary UCSF Experience with EAM EAM Endo Endo Asst Transfacial 32 Total Patients with Lateral Lesions (50% malignant) 16 patients with EAM 3 Endo-assisted sublabial approach 6 with purely open approach (15%) OZM No Patients

14 Results Sequential Approach: JNA Of 16 Patients with EAM 9 (56%) extended lateral to V2 nerve 11/16 (68%) complete resection 4 planned subtotal resection 1 determined unresectable 1) Gain Early Anterior Lateral Access 2) Work From Lateral ) Remove Posterior Attachment Medially CONVERT TO OPEN IF NEEDED Sub-labial Extension as Necessary Superior Access to G Sph Wing Posterior Inferior to Carotid

Retracted Ala *Photo consent obtained 57 58 Step Ladder Approach to Lateral Lesions Endoscopic Trans-nasal/Trans-septalseptal Endoscopic Anterior

15 Post Op Appearance EAM Expected Deficits 1 year 3 weeks Numbness Incisor teeth and peri-alar skin Most recover by 6-12 months * * Epiphoria can occur Nasolacrimal duct transected DCR? Retracted Ala *Photo consent obtained Step Ladder Approach to Lateral Lesions Endoscopic Trans-nasal/Trans-septalseptal Endoscopic Anterior Maxillotomy Sublabial Incision Transfacial Approach Endoscope Provides Decent Access to Central, Anterior, Lateral Skull Base Approaches should be part of a step ladder approach including open options when necessary. Conclusion No Looking Back?

10/23/2010. Excludes Single Surgeon Pituitary (N=~140) Skull Base Volume 12 Month UC SF. Patients. Anterior/Midline. Pituitary CSF Leak.

10/23/2010. Excludes Single Surgeon Pituitary (N=~140) Skull Base Volume 12 Month UC SF. Patients. Anterior/Midline. Pituitary CSF Leak. Advances in Pituitary Surgery Ivan El-Sayed MD, FACS Director- Otolaryngology Minimally Invasive Skull Base Surgery Program Otolaryngology-Head and Neck Surgery University of California-San Francisco Minimally