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JORMAS 69 1–3 J Stomatol Oral Maxillofac Surg xxx (2017) xxx–xxx
Available online at
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53rd SFSCMFCO Congress
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Endoscopic surgery for sinonasal tumors: The transcribriform approach§ Q1 R. a b c
Thomas a,b, P. Martin a, D. Patrick a,c, M. Justin a,b,*
Department of Otolaryngology, Head and Neck Surgery, La Conception University Hospital Center, 147, boulevard Baille, 13385 Marseille cedex, France IUSTI, UMR 7343 CNRS AMU, 5 rue Enrico-Fermi, 13453 Marseille cedex 13, France Departement of Anthropolgy, ADES UMR 7268 CNRS Aix Marseille University EFS, faculte´ de me´decine Nord, 51, boulevard Pierre-Dramart, 13015 Marseille,
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 June 2017 Accepted 9 June 2017
Over the past 10 to 20 years, endoscopic endonasal surgery has become for many teams the preferred treatment for sinonasal tumors. Technical advances in the field of surgical instrumentation (good visualization, hemostasis. . .) and the progress of imaging guidance (to avoid neurovascular complication) has made those procedures simpler and safer. Nevertheless, endonasal endoscopic procedures require a trained surgical team of ENT specialist and neurosurgeon. Endoscopic endonasal surgery has been reported to be feasible for all types of sinonasal tumors whether benign tumors such as inverted papillomas, or malignant tumors. In this paper, we mostly focus on the principles underlying the transcribriform approach, which is dedicated to the surgery of CSF leaks, encephaloceles/ meningoceles, access to benign intracranial tumors such as olfactory groove meningiomas, and the resection of sinonasal malignancies with skull base invasion such as olfactory neuroblastomas.
C 2017 Elsevier Masson SAS. All rights reserved.
Keywords: Sinus carcinoma Surgery Benign tumors Treatment
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France
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1. Introduction
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Over the past 10 to 20 years, endoscopic endonasal surgery has become, for many teams, the preferred treatment for sinonasal tumors. Technical advances in the field of surgical instrumentation (good visualization, hemostasis. . .) and the progress in imaging guidance (to avoid neurovascular complications) has made these procedures simpler and safer [1,2]. Nevertheless, endonasal endoscopic procedures require a trained surgical team of ENT specialist and neurosurgeon. The numerous advantages of endoscopic procedures, as opposed to transfacial and transcranial approaches, include shorter surgery time and length of stay, no external incision, decreased brain parenchyma injury, no neurovascular structure manipulation [3,4] and, probably the major benefit, no difference in oncological results even if piecemeal resection is required [1]. Endoscopic nasal resection is a safe surgical option in the
management of sinonasal adenocarcinomas [5–7]. In a recent meta-analysis including 1826 cases [8], it showed low rates of major complications compared to open approaches. Moreover, the incidence of local failure was lower in the endoscopic surgery group compared with open approach patients [8]. Endoscopic endonasal surgery has been reported to be feasible for all types of sinonasal tumors, whether benign (such as inverted papillomas) or malignant. In this paper, we will mostly focus on the principles underlying the transcribriform approach, which is devoted to the surgery of CSF leaks, encephaloceles/meningoceles, access to benign intracranial tumors, such as olfactory groove meningiomas, and the resection of sinonasal malignancies with skull base invasion, such as olfactory neuroblastomas.
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2. Surgical procedures: general principles
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2.1. Bilateral exposure
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Endoscopic surgery for sinonasal tumors often involves a bilateral approach [1], thus requiring 3 or 4 hand surgeries. Tissue dissection is facilitated by this bilateral approach providing space
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§
Article reported from the 53rd SFSCMFCO Congress (Marseille, October 4–7, 2017) and published under the responsibility of the Scientific Committee of the congress. * Corresponding author. E-mail address:
[email protected] (M. Justin). http://dx.doi.org/10.1016/j.jormas.2017.06.015 C 2017 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Thomas R, et al. Endoscopic surgery for sinonasal tumors: The transcribriform approach. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.jormas.2017.06.015
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for instrument manipulation. Nasal septum resection offers wide access to the skull base.
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2.2. Resection
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The development of endoscopic sinus surgery has greatly expanded therapeutic possibilities. It enables fine and narrow tissue dissection, selective coagulation of vessels and management of resection margins with optimal visual control. Different methods of tumor resection are available: ablation with forceps, a shaver or an ultrasonic suction aspirator.
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3. Modular approaches
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Endoscopic endonasal approaches have been organized in modules based on anatomical areas [14,15]. We will mainly describe the transcribriform approach, which gives access to the anterior skull base and dura mater. Numerous modes of pathology management are possible with the transcribriform technique including encephaloceles or meningoceles treatment, repair of CSF leaks, and access to benign intracranial tumors such as meningiomas. Moreover, this approach also gives access from the anterior skull base to malignant tumors such as adenocarcinomas and olfactory neuroblastomas. Olfaction is sacrificed during this technique although, in many patients, it was probably already compromised by the disease.
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3.1. Exposure
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With this approach, the forward limits are the crista galli and the frontal sinuses, the backward limit the sphenoidal planum, and the lateral limit the papyracea laminae. The procedure can be performed unilaterally or bilaterally and allows en bloc resection of the anterior skull base. First, both anterior and posterior ethmoidectomies are performed. Anteriorly, the two frontal recesses are visualized and posteriorly, the anterior wall of the sphenoidal sinus can be removed, if necessary. Laterally, the papyracea laminae are preserved or removed according to carcinological requirements. The upper part of the nasal septum (attached on the base of the skull) is resected. The two anterior and posterior ethmoidal arteries are selectively coagulated, often enabling the tumor to be devascularized. A frontal sinusotomy is required but its extent and laterality varies according to the extent of the disease and the exposure needed. The skull base is then drilled laterally near the papyracea lamina, then forward and backward, taking care to have previously coagulated the ethmoidal arteries. After bilateral removal of the cribriform plate, the crista galli are drilled and removed. This last step often requires 4 hands, a surgeon pulling the crista galli downward and backward, thus enabling the main operator to dissect it more easily.
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3.2. Intradural dissection
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The dura is coagulated and incised individually on both sides of the falx. The tumor is resected almost entirely, except on its attachment site. Extracapsular dissection is performed by sharp dissection and gentle counter-traction (4-hands procedure).
We use 2 types of material for closure of skull base defects: fascia lata and/or fat. Fascia lata is the most used autologous graft in the literature. Its main advantages are ease of harvesting, its large size suitable for bigger defects, and its texture and resistance, which limit the occurrence of encephalocele. It can be used in the underlay technique (the graft is placed between the dura and the bone) and/ or in the overlay technique (the graft is placed between the bone and the mucosa). Fat can be used as a fat plug or as obliteration material. Abdominal fat is hydrophobic and contains stem cells, making it an excellent choice, especially for limited losses of substance. The use of biological glue, between the layers of fascia lata or in the abdominal fat, ensures good initial stabilization. In large defects, our preference is fascia lata. In all cases, the use of silicone under the reconstruction prevents encephalocele. The silicone is usually removed one month after surgery during the consultation. There are many other surgical procedures, such as the transclival, transsphenoidal and transodontoid approaches, depending on the areas of resection needed, but which will not be treated here.
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5. Postoperative care
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There are no uniform recommendations in the literature about postoperative care. Packing, duration of bed-rest and the use of a lumbar drain are dependent on the surgical team’s usual practice. Generally, we use neither packing nor a lumbar drain at the end of the transcribriform procedure. We recommend 4 to 8 days bed rest after surgery. Antibiotic prophylaxis is advised in case of a high risk of infection. According to the literature, monotherapy is preferred, notably by cefazoline or ceftazidime. Alternative single-agent antibiotic regimes are based on amoxicillin-clavulanate; in case of suspected allergy, vancomycin or clindamycin may be administered [15].
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6. Surgical margins
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Piecemeal resection of malignant tumors is needed using endoscopic endonasal procedures. This procedure does not seem to compromise oncologic results provided clear margins are confirmed by frozen section or histological analysis [15]. The French team of Bastier et al. [18] has published a diagram of the sinonasal cavities to help surgeons, pathologists and radiologists to evaluate margins postoperatively. This three-dimensional diagram facilitates understanding of tumor size, location and extensions. It also enhances case presentations and communication in multidisciplinary team meetings.
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Funding
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None.
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Ethical approval 96
4. Transnasal endoscopic closure of skull base defects
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There is a wide variety of materials, both autologous and heterologous, to close CSF leaks and dural defects. In the literature, there is a preference for autologous materials, which avoid potential risk of infection [16,17].
Not required. Disclosure of interest The authors declare that they have no competing interest.
Please cite this article in press as: Thomas R, et al. Endoscopic surgery for sinonasal tumors: The transcribriform approach. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.jormas.2017.06.015
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Q2 Uncited references
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Please cite this article in press as: Thomas R, et al. Endoscopic surgery for sinonasal tumors: The transcribriform approach. J Stomatol Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.jormas.2017.06.015
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