Endoscopic Transcanal Transpromontorial Removal of an Intracochlear Schwannoma and Traditional Cochlear Implantationvideo
Vestibular schwannomas (acoustic neuromas) develop due to mutations in Schwann cells that cause uncontrolled cell division. As a result, a tumor forms. As these tumors grow, they can compress the cochlear nerve causing unilateral hearing loss and tinnitus. Vestibular schwannomas may cause imbalance and occasionally vertigo. Intralabyrinthine schwannomas account for about 10% of vestibular schwannomas in centers that specialize in temporal bone imaging. Intracochlear schwannomas are the most common type of intralabyrinthine schwannomas. In this video, we describe an endoscopic transcanal transpromontorial approach to intracochlear schwannoma removal. This surgery was performed by James Prueter, DO, of Southwest Ohio ENT Specialists in Dayton, OH. Video editing was performed by Austin Miller, OMS-II, Ohio University Heritage College of Osteopathic Medicine.
This is a demonstration of the retrosigmoid approach for microsurgical resection of a cerebellopontine angle tumor. Th patient presented with gait disturbance and normal hearing. A suboccipital craniotomy was used for access to the cerebellopontine angle. Using microsurgical technique, the tumor was dissected away from the glossopharyngeal nerve. Pathological analysis confirmed that the tumor was a schwannoma of the glossopharyngeal nerve. DOI# http://dx.doi.org/10.17797//r3wbfb5hkv
Chiari decompression is a common neurosurgical procedure. Chiari malformations present with a number of symptoms including Valsalva-induced headaches, swallowing dysfunction, and sleep apnea. Chiari malformations can also cause syringomyelia and syringobulbia. Surgical procedures used for the treatment of Chiari malformation include bone-only decompression (posterior fossa craniectomy +/- cervical laminectomy), craniectomy/laminectomy with duraplasty, and craniectomy/laminectomy/duraplasty with shrinkage or resection of the cerebellar tonsils. The procedure used depends on the specifics of the patient’s condition and the preference of the surgeon. The patient presented here had undergone a prior Chiari decompression at the age of 20 months. This was bone-only with posterior fossa craniectomy and C1-2 laminectomy. The dura was not opened due to the presence of a venous lake. He initially had improvement in his symptoms. However, his headaches and snoring recurred, balance worsened, and dysphagia never improved. Therefore, a repeat Chiari decompression at the age of 28 months was performed as presented here.
Contributors: M. Nathan Nair and Timothy Deklotz For patients with basilar invagination, an odontoidectomy may be necessary to decompress the brainstem, before further correction and stabilization of the craniocervical junction can be achieved. The open-mouth odontoidectomy procedure is associated with significant moribdity, and the endoscopic endonasal approach may be a better option. In this video, we provide a step-by-step demonstration of the endoscpic endonasal approach for odontoidectomy. DOI:http://dx.doi.org/10.17797/6mx9qe789f
Contributors: Daniel Felbaum and H. Jeff Kim The video demonstrates the resection of a trigeminal schwannoma via a middle fossa craniiotomy and anterior petrosectomy. A large dumbbell-shaped tumor was essentially two tumors in one. The anterior petrosectomy provided access mainly to the posterior component of the tumor, which was compressing the pons, and obscured by the tentorium and petrous ridge. Mobilization of the lateral wall of the cavernous sinus freed the anterior component and thus allowed the removal of the rest of the schwannoma. DOI# http://dx.doi.org/10.17797/8hbvtjdj0l
Cranioplasty with barrel stave osteotomies to treat sagittal suture craniosynostosis.
Contributors: Ravi N. Samy, M.D., F.A.C.S (University of Cincinnati / CCHMC) and Shawn Stevens, M.D. Cholesterol granuloma recurrence at the petrous apex. The patient had a prior surgery performed without stenting. Revision surgery at UC performed with double-barrel stent placement. External Related Links: www.cisurgeon.org www.youtube.com/user/cisurgeon DOI: http://dx.doi.org/10.17797/vvmrb6t77g Editor Recruited By: Ravi N. Samy, MD, FACS
Contributors: Micheala Lee This is a demonstration of using the transventricular and subtemporal corridors for resecting a large middle fossa, tentorial meningioma. The video details the microsurgical technique for detaching the tumor from the tentorial incisura, working near critical structures such as the oculomotor nerve, trochlear nerve, and posterior communiating artery. It also includes precise demonstration of how to separate the massive tumor from the feeding arterial supply stemming from the posterior cerebral artery. DOI: https://doi.org/10.17797/nbtj2jdx6l
This video demonstrates a transcanal endoscopic infracochlear approach to the petrous apex in a patient with a large cholesterol granuloma. The patient presented with a history of profound left sensorineural hearing loss, hemifacial spasm, and House Brackmann Grade 2 facial function. Preoperative imaging demonstrated a T1 and T2 hyperintense heterogenous lesion in both petrous apices with the left being larger than the right on magentic resonance imaging. A computed tomography scan (CT) of the temporal bones demonstrates extension of the left petrous apex lesion into the internal auditory canal and cochlea. Dr. Isaacson has had 2 patients who have had significant recovery of their bone line after using an infracochlear approach. In the unlikely event that the patient experiences hearing loss in the other ear, their cochlea is preserved for a possible CI. However, the patients hearing loss is likely secondary to the 8th nerve involvement of cholesterol granuloma erosion into IAC. The patient in this surgical video has been monitored for a year. One year postop CT shows aeration of the apex. This patient's facial spasm has resolved. Dr. Isaacson has used stents in the past, but in this case felt the opening was large enough that he could forego it. Patient did not recover their hearing. DOI: http://dx.doi.org/10.17797/1wq11j68wa
Contributors: Jacob B. Hunter, Reid C. Thompson and David S. Haynes Superior semicircular canal dehiscence (SCD) is a condition in which the bone overlying the superior semicircular canal is absent. The clinical presentation of SCD is highly variable and may include both auditory and vestibular manifestations. The more common symptoms include autophony, sound or pressure induced vertigo, hypersensitivity to sound, and low frequency conductive hearing loss. Repair can be accomplished via either transmastoid or middle fossa approaches, with numerous materials used to either plug or resurface the canal. Herein, we describe our resurfacing technique using a loose areolar tissue-bone pâté-loose areolar tissue sandwich through a middle fossa approach. DOI#: http://dx.doi.org/10.17797/kcwvab3b7r
Contributors:Michael Golinko, MD, MA, Eylem Ocal, MD and Kumar Patel, PA Premature metopic suture fusion is corrected using fronto-orbital advancement and cranial vault remodeling to open the fused suture and allow for adequate brain growth. DOI#: https://doi.org/10.17797/hg9xbuxoms
Contributors: Fadi Sweiss Microvascular decompression is the most effective surgical procedure for treating trigeminal neuralgia in patients with classic symptoms. Here we present a patient who had a "duo crush" from both a vein, as well as a loop of the superior cerebellar artery. The key maneuvers to create space between the compressive element and the nerve, in order to secure the teflon "cushion," are highlighted. DOI: https://doi.org/10.17797/qgthi9k07c
Contributors: H. Jeffrey Kim The translabyrinthine approach has often been reserved for large acoustic neuromas because it requires less retraction on the cerebellum when compared to the retrosigmoid approach for a similar tumor. However, the translabyrinthine approach is equally useful for smaller tumors, when the patients has no residual ipsilateral hearing. It allows for early visualization of the facial nerve, and thus better protection of this crucial nerve. DOI #: http://dx.doi.org/10.17797/168b12z8m4
Contributors: Daniel R. Felbaum Microvascular decompression is the most effective surgical procedure for treating trigeminal neuralgia in patients with classic symptoms. The most frequent compressive force is the superior cerebellar artery. Here we demonstrate the procedure in a patient with long-standing, classic symptoms of trigeminal neuralgia, in whom we discovered compression from venous structures. DOI# http://dx.doi.org/10.17797//henaevqy2g
Contributors: Bruce E. Mickey and J. Walter Kutz This video highlights key steps to the translabyrinthine approach for vestibular schwannoma resection. It emphases identification of the facial nerve and the benefit of facial nerve monitoring in lateral skull base surgery. DOI#: https://doi.org/10.17797/4w83z6uxam
Contributors: Timothy R. DeKlotz With the widespread use of the endoscope in pituitary surgery, many technical nuances have emerged. Some surgeons still use a sublabial incision and a speculum, despite using the endoscope for visualization, while others favor approaches that are purely endonasal. Some surgical teams, using an endoscope-holder, work sequentially and individually, while others prefers two surgeons working together simultaneously. In this video, we demonstrate an endoscopic endonasal approach, in which the tumor resection is performed with a 4-hand technique with both surgeons working simultaneously. DOI#: http://dx.doi.org/10.17797//bdxmmtst16
Myelomeningocele is the most common form of neural tube defect, developing after the 4th week of gestation. Although diagnosed prenatally, many patients did not have a chance to be treated before birth. The best approach in these situation is to perform surgical treatment at time zero. A multidisciplinary team must be prepared to perform dural repair and soft tissue coverage. This video illustrates our approach for soft tissue reconstruction using rhomboid fasciocutaneous flaps with maximal preservation of perforator vessels. Contributors Dov Charles Goldenberg, MD Phd, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School Vania Kharmandayan, MD, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School Tatiana Moura, MD, MSc, Division of Plastic Surgery, Hospital das Clinicas, University of Sao Paulo Medical School
An endoscopic third ventriculostomy (ETV) can be a sufficient alternative to a cerebral shunt in the treatment of noncommunicating forms of hydrocephalus. Hydrocephalus can present with numerous signs and symptoms, including headache, vomiting, neck pain, macrocephaly, and vision impairment. Surgical procedure includes entrance of the lateral ventricles through a bur hole, and blunt/cautery fenestration of the third ventricular floor, which lies between the mamillary bodies and tuber cinereum. Choroid plexus cautery has been noted in the literature as being a viable addition to the procedure, in which a reduction in CSF production is achieved. Though, exact surgical procedure is left to the discretion of the surgeon. The patient presented is a 30-month-old boy with non-communicating obstructive hydrocephalus secondary to congenital aqueductal stenosis. The patient has a history of progressive developmental delays, balance issues, and increased seizure frequency from a known seizure disorder. Therefore, an endoscopic third ventriculostomy via right frontal approach was elected. Authors: William Fuell, Marcus Stephens M.D., Eylem Ocal M.D. Institutions: Arkansas Children's Hospital, University of Arkansas for Medical Sciences
This video demonstrates the operative setup and surgical steps of a middle fossa approach for the resection of vestibular schwannoma (acoustic neuroma). Authors: Cameron C. Wick, MD (firstname.lastname@example.org) 1 Samuel L. Barnett, MD (email@example.com) 2 J. Walter Kutz Jr., MD (firstname.lastname@example.org) 3 Brandon Isaacson, MD (email@example.com) 3 1 - Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 2 - Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX 3- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX
This procedure is a total calvarial vault expansion to correct pansynostosis in a three-year-old child. Total calvarial reconstruction is an open procedure that consists of removing bone flaps with an osteotome, outfracturing the skull bone edges with a rongeur to allow for future expansion, shaving down the bone flap inner table with a Hudson brace to create a bone mush for packing the interosseus spaces, and modifying then reattaching the bone flaps with absorbable plates and screws. This patient is status post craniofacial reconstruction for earlier sagittal synostosis. Second operations are uncommon after correction of single-suture synostosis, so this more aggressive technique represents an attempt to definitively correct the calvarial deformity and resolve the signs and symptoms of the attendant intracranial hypertension. Indications for surgery include cosmetic and neurologic concerns, here including a Chiari malformation and cervicothoracic syrinx. This educational video is related to a current research project of the Children’s National Medical Center Division of Neurosurgery regarding single-suture craniosynostosis and the factors that place children at risk for surgical recidivism in the setting of intracranial hypertension. Kelsey Cobourn, BS - Children's National Medical Center Division of Neurosurgery and Georgetown University Owen Ayers - Children's National Medical Center Division of Neurosurgery and Princeton University Deki Tsering, MS - Children's National Medical Center Division of Neurosurgery Gary Rogers, MD, JD, MBA, MPH - Children's National Medical Center Division of Plastic and Reconstructive Surgery and George Washington University School of Medicine Robert Keating, MD - Children's National Medical Center Division of Neurosurgery and George Washington University School of Medicine (corresponding author)
The conventional approach to the lumbar discectomy requires significant tissue dissection to obtain a sufficient working space and is known to cause possible complications and injuries. The minimally invasive, fully endoscopic uniportal interlaminar discectomy provides numerous advantages to the typical open procedure. Some advantages include: good visualization of anatomical structures utilizing continuous lavage; lower rates of operative complications such as dural injury, bleeding, and infection; and shorter hospitalization, with increased post-operative rehabilitation. Surgical procedure utilizes guided fluoroscopy to gain access to the interlaminar window, with subsequent placement of the working channel endoscope. Microscopic debridement of herniated lumbar disc and decompression of nerve roots is conducted. This case highlights a patient with significant disc herniation at the L5-S1 level with concurrent mild to moderate cervicothoracic scoliosis. The patient elected for the minimally invasive, fully endoscopic interlaminar microdiscectomy. Authors: William Fuell, Eylem Ocal M.D., Salih Aydin M.D. Institutions: Emsey Hospital-Istanbul, Arkansas Children’s Hospital
Hepzibha Alexander, BSN – Children’s National Medical Center, Division of Neurosurgery and Georgetown University School of Medicine Ehsan Dowlati, MD - Children’s National Medical Center, Division of Neurosurgery and Medstar Georgetown University Hospital Deki Tsering, MS - Children’s National Medical Center, Division of Neurosurgery Robert Keating, MD - Children’s National Medical Center, Division of Neurosurgery and George Washington University School of Medicine (corresponding author)
A 51 year-old male presented to an outside otolaryngologist with recurrent facial pain and congestion. He was found to have a left-sided nasal mass. A work-up was performed, complete with biopsy, which was diagnosed as non-intestinal type adenocarcinoma. He underwent resection via the endoscopic endonasal transcribriform approach. In this video publication, we present our preferred method of reconstruction for sinonasal malignancies treated by endoscopic transcribriform resection using a multilayered closure with the following: a subdural DuraGen inlay graft, a fascia lata onlay graft, and an extradural, extracranial onlay pericranial flap via nasionectomy. A lumbar drain was placed at the end of the case for CSF diversion until the fifth postoperative day. Contributors: Paul A. Gardner, MD, Eric W. Wang, MD, Juan C. Fernandez-Miranda, MD, and Carl H. Snyderman, MD, MBA
A 31 year-old male presented with diplopia and was found to have left sixth nerve palsy on physical examination. Work-up with MRI revealed a hypointense mass on T2 images involving the mid to lower clivus with penetration of the posterior fossa dura. The patient had no complaints of nasal obstruction, no prior nasal surgery or nasal trauma. Intraoperative frozen section analysis revealed chordoma. Author Note: minute 3:41 "rostrum" was spelled incorrectly. Contributor: Eric Wang
Authors: Gavriel D. Kohlberg, MD - University of Cincinnati Noga Lipschitz, MD - University of Cincinnati Charlie Poff, BS - Medical University of South Carolina Ravi N. Samy, MD, FACS - University of Cincinnati
Contributors: Ehab Hanna and Peleg Horowitz Anterior skull base sinonasal malignancy previously biopsied as esthesioneurobastoma. Tumor extension through the left cribiriform plate and left lamina papyracea. Author Recruited By: Dr. Ehab Hanna
- Professor and Chief of Neurosurgery
Robert Keating, MD is currently Professor and Chief of Neurosurgery at the Children’s National Medical Center in Washington, DC. Dr. Keating graduated from Georgetown University Medical School in 1983 and subsequently went to New York where he did his training in Neurosurgery at the Albert Einstein and Montefiore Medical Center in the Bronx. A fellowship in Pediatric Neurosurgery as well as Craniofacial Surgery followed at Einstein / Montefiore in 1990.
Subsequent to his training, Dr Keating served in the Navy and was stationed at the Oakland Naval Hospital from 1990-1994, during which time he served as the Chief from ’91 to ’94. He then returned briefly for 2 years to the Bronx where he was on staff at Montefiore Medical Center as well as the Bronx Municipal Hospital Center. He came back to Washington in 1996 to join the faculty at the Children’s National Medical Center and later became Chief of the Division of Neurosurgery in 2003 and Professor of Neurosurgery and Pediatrics in 2008. His past appointments include the President of the Medical Staff at the Children’s National Medical Center as well as Head of Credentials and he currently maintains a busy practice of pediatric neurosurgery, with an emphasis on tumors, Chiari malformations, craniofacial reconstruction, spinal dysraphism, spasticity and brachial plexus surgery. As a member of the American Society of Pediatric Neurosurgery and International Society of Pediatric Neurosurgery, he has published and presented extensively in the field. His publications include the previous texts, “An Atlas of Orbitocranial Surgery” and “Tumors of the Pediatric Nervous System” (2nd edition published in 2013) with current work on Neurosurgical Operative Atlas, (2nd ed. Goodrich JT, and Keating RF, Thieme) due for publication in 2017. He is also Chair, Medical Advisory Committee on the Board of the American Syringomyelia Alliance Project as well as a founding member of the Posterior Fossa Society and maintains long-standing membership in the CNS, AANS, ASPN and ISPN.
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