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
Endoscopic endonasal resection of anterior skullbase sinonasal tumor, with dural resection and Alloderm button-graft intradural/epidural reconstruction. Left lamina papyracea resected as well. Surrounding dural margins are biopsied and are negative.
Sinonasal malignancy with extension through the anterior skull base and dura
Extension superolateral to the lamina papyracea would require cranial transbasal approach. Involvement/encasement of intracranial vessels would also be more safely managed transcranially.
Endoscope and tower, intraoperative navigation, endoscopic drill, monopolar and bipolar cautery. Patient supine with slight back elevation to reduce venous pressure, and head tilted left for surgeon comfort. Head extended slightly compared to trans-sphenoidal approach. Right thigh prepped for possible fascia lata graft. Possible lumbar drainage.
MRI with high-resolution 3D T1 post-contrast; sinus and neck CT with contrast; PET scan to rule out distant disease.
Advantages: Endoscopic approach provides excellent visualization of the pathology, without need for bicoronal incision.
Disadvantages: Potential for CSF fistula formation is theoretically greater than for transcranial approach with vascularized pericranial graft; inability to clear negative margins over both orbital roofs.
Risks: Spinal fluid fistula, meningitis, injury to anterior cerebral arteries, injury to optic nerve/orbital contents.
Risks: Spinal fluid fistula, meningitis, injury to anterior cerebral arteries, injury to optic nerve/orbital contents.
N/A
1. Endoscopic resection of sinonasal cancers. Su SY, Kupferman ME, DeMonte F, Levine NB, Raza SM, Hanna EY. Curr Oncol Rep. 2014 Feb; 16(2):369. PMID: 24445501.
Review Endoscopic Endonasal Resection of an Esthesioneuroblastoma with Dural Resection and Reconstruction. Cancel reply
Related Videos
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Endoscopic Endonasal Resection of an Esthesioneuroblastoma with Dural Resection and Reconstruction.