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Endoscopic Techniques for Pathology of the Anterior Cranial Fossa and Ventral Skull Base
LETTERS
Endoscopic Techniques for Pathology of the Anterior Cranial Fossa and Ventral Skull Base
cept of team surgery. In recent years, there has been a stepwise progression of endoscopic neurosurgery with the description of unfamiliar endoscopic anatomy, development of supporting technologies adapted to transnasal endoscopic approaches (endoscopic skull base instruments, image guidance systems, ultrasonic aspirators), and perfection of reconstruction techniques.The entire ventral cranial base can now be reached using transnasal endoscopic approaches. Using a modular approach to the ventral skull base, the surgical field extends from the frontal sinus to C2 in the sagittal plane and from the sella to the jugular bulb in the coronal plane.8-10 Remaining challenges include defining the limitations of endoscopic techniques, reporting outcomes data comparing endoscopic and open techniques, and training of a new generation of “endoneurosurgeons.” We only need to look at the evolution of endoscopic surgery in other surgical specialties to understand the impact that endoscopic techniques will have in the areas of cranial base surgery and neurosurgery. Dr Brown was invited to reply but did not. —Editor.
Carl H Snyderman, MD, FACS Amin B Kassam, MD Pittsburgh, PA This year’s update on “What’s New in Neurologic Surgery?”1 fails to mention an important change in the surgical practice of neurosurgery—the adoption of endoscopic techniques for treatment of pathology of the anterior cranial fossa and ventral skull base. Although adoption of endoscopic techniques for pituitary surgery is discussed in “What’s New in Otolaryngology?,”2 the potential applications for other areas of the cranial base are only suggested. The juxtaposition of the same updates in last year’s issue3,4 provides an opportunity to highlight the value of collaboration between these two specialties. Tremendous advancements have been achieved in cranial base surgery as a result of this collaboration. Although use of nasal endoscopes is commonplace in otolaryngology for treatment of sinonasal diseases and cerebrospinal fluid leaks, it is only in recent years that neurosurgeons have explored their use for intracranial and extracranial operations, including ventricular operation, posterior fossa nerve decompression, transcranial aneurysm operation, and spine operation. Use of minimally invasive techniques is quickly becoming the standard of care for pituitary tumors, even in the presence of cavernous sinus or suprasellar extension.5 In comparison to microscopic techniques, endoscopic techniques allow better visualization and more complete tumor resection without an increase in morbidity. At the 16th Annual Meeting of the North American Skull Base Society and the 7th European Skull Base Society Congress in 2005, multiple presentations demonstrated the feasibility and safety of endoscopic techniques for a wide variety of tumors involving the anterior cranial base.6,7 These include completely endoscopic “craniofacial” resections for esthesioneuroblastomas, clival chordomas, and olfactory groove meningiomas. It needs to be stressed that these advances are only possible with the active collaboration of otolaryngology and neurosurgery within the con-
© 2006 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. Brown JA. What’s new in neurologic surgery? J Am Coll Surg 2005;200:932–936. 2. Couch M. What’s new in otolaryngology? J Am Coll Surg 2005; 201:101–109. 3. Weissler MC, Scharer S. What’s new in otolaryngology—head and neck surgery? J Am Coll Surg 2004;199:114–123. 4. Grady MS. What’s new in neurologic surgery? J Am Coll Surg 2004;199:109–113. 5. Carrau RL, Kassam AB, Snyderman CH. Pituitary surgery. Otolaryngol Clin North Am 2001;34:1143–1155. 6. Presentation abstracts, 16th Annual Meeting of the North American Skull Base Society. Skull Base 2005;15[Suppl 1]. 7. Presentation abstracts, 7th European Skull Base Society Congress. Skull Base 2005;15:[Suppl 2]. 8. Kassam A, Snyderman CH, Mintz A, et al. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 2005;19:E3. 9. Kassam A, Snyderman CH, Mintz A, et al. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 2005;19:E4. 10. Kassam A, Gardner P, Snyderman CH, et al. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 2005;19:E6.
563
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.11.019
Endoscopic Techniques for Pathology of the Anterior Cranial Fossa and Ventral Skull Base
cept of team surgery. In recent years, there has been a stepwise progression of endoscopic neurosurgery with the description of unfamiliar endoscopic anatomy, development of supporting technologies adapted to transnasal endoscopic approaches (endoscopic skull base instruments, image guidance systems, ultrasonic aspirators), and perfection of reconstruction techniques.The entire ventral cranial base can now be reached using transnasal endoscopic approaches. Using a modular approach to the ventral skull base, the surgical field extends from the frontal sinus to C2 in the sagittal plane and from the sella to the jugular bulb in the coronal plane.8-10 Remaining challenges include defining the limitations of endoscopic techniques, reporting outcomes data comparing endoscopic and open techniques, and training of a new generation of “endoneurosurgeons.” We only need to look at the evolution of endoscopic surgery in other surgical specialties to understand the impact that endoscopic techniques will have in the areas of cranial base surgery and neurosurgery. Dr Brown was invited to reply but did not. —Editor.
Carl H Snyderman, MD, FACS Amin B Kassam, MD Pittsburgh, PA This year’s update on “What’s New in Neurologic Surgery?”1 fails to mention an important change in the surgical practice of neurosurgery—the adoption of endoscopic techniques for treatment of pathology of the anterior cranial fossa and ventral skull base. Although adoption of endoscopic techniques for pituitary surgery is discussed in “What’s New in Otolaryngology?,”2 the potential applications for other areas of the cranial base are only suggested. The juxtaposition of the same updates in last year’s issue3,4 provides an opportunity to highlight the value of collaboration between these two specialties. Tremendous advancements have been achieved in cranial base surgery as a result of this collaboration. Although use of nasal endoscopes is commonplace in otolaryngology for treatment of sinonasal diseases and cerebrospinal fluid leaks, it is only in recent years that neurosurgeons have explored their use for intracranial and extracranial operations, including ventricular operation, posterior fossa nerve decompression, transcranial aneurysm operation, and spine operation. Use of minimally invasive techniques is quickly becoming the standard of care for pituitary tumors, even in the presence of cavernous sinus or suprasellar extension.5 In comparison to microscopic techniques, endoscopic techniques allow better visualization and more complete tumor resection without an increase in morbidity. At the 16th Annual Meeting of the North American Skull Base Society and the 7th European Skull Base Society Congress in 2005, multiple presentations demonstrated the feasibility and safety of endoscopic techniques for a wide variety of tumors involving the anterior cranial base.6,7 These include completely endoscopic “craniofacial” resections for esthesioneuroblastomas, clival chordomas, and olfactory groove meningiomas. It needs to be stressed that these advances are only possible with the active collaboration of otolaryngology and neurosurgery within the con-
© 2006 by the American College of Surgeons Published by Elsevier Inc.
REFERENCES 1. Brown JA. What’s new in neurologic surgery? J Am Coll Surg 2005;200:932–936. 2. Couch M. What’s new in otolaryngology? J Am Coll Surg 2005; 201:101–109. 3. Weissler MC, Scharer S. What’s new in otolaryngology—head and neck surgery? J Am Coll Surg 2004;199:114–123. 4. Grady MS. What’s new in neurologic surgery? J Am Coll Surg 2004;199:109–113. 5. Carrau RL, Kassam AB, Snyderman CH. Pituitary surgery. Otolaryngol Clin North Am 2001;34:1143–1155. 6. Presentation abstracts, 16th Annual Meeting of the North American Skull Base Society. Skull Base 2005;15[Suppl 1]. 7. Presentation abstracts, 7th European Skull Base Society Congress. Skull Base 2005;15:[Suppl 2]. 8. Kassam A, Snyderman CH, Mintz A, et al. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 2005;19:E3. 9. Kassam A, Snyderman CH, Mintz A, et al. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 2005;19:E4. 10. Kassam A, Gardner P, Snyderman CH, et al. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 2005;19:E6.
563
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.11.019