A new powered endoscope holding arm for endoscopic surgery of the cranial base.

Over the past 20 years endoscopy has become an essential part of nearly all surgical specialities. In the field of skull base surgery recent articles describe new applications and highlight improved results in pituitary adenoma removal, vascular decompression surgery, and in the resection of many other skull base tumors. The strength of the endoscope in skull base surgery lies in its ability to see behind bony apices and neurovascular structures, which normally obscure the view of the operating microscope. Paramount to the success of the endoscope in skull base and pituitary surgery is the ability to secure the arm in position. Operating in the confined spaces of the skull, the instability and difficult adjustment of currently available endoscope holding arms is cumbersome for the surgeon and dangerous to the patient. Many surgeons have commented that the currently available endoscope holding arms are inadequate for contemporary applications of endoscopic skull base surgery. In this article we describe a new pneumatically powered endoscope holding arm, which provides the level of stability and ease of adjustment necessary for current and future applications of endoscope skull base surgery.

Fully endoscopic vascular decompression of the trigeminal nerve.

Microvascular decompression of the trigeminal nerve is an accepted and effective means of treating patients with trigeminal neuralgia in whom compression of the nerve by a vascular structure is implicated in the pathogenesis of the disease. The current standard technique uses the binocular operating microscope for all intra-operative visualization. Posterior fossa endoscopy has demonstrated that the endoscope provides more comprehensive views of the anatomy of the cerebellopontine angle than does the operating microscope. To date, endoscopy has only been used to supplement microscopy in cranial nerve decompression surgery. In this report, we describe our completely endoscopic surgical technique as we present the case of a patient with trigeminal neuralgia who underwent successful vascular decompression by this approach. Using this technique the offending vessel was separated from the nerve with minimal brain retraction or dissection of surrounding structures. This report represents the first documented case where the endoscope was used as the exclusive imaging modality for decompression of the trigeminal nerve. From our experience we conclude that the endoscope's superior visualization more accurately identifies neurovascular conflicts, and provides a comprehensive evaluation of the completeness of the decompression. Additionally, this new method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. From this study we conclude that completely endoscopic vascular decompression represents the next step forward in the safe and effective surgical treatment of trigeminal neuralgia.

A rare symptomatic presentation of ecchordosis physaliphora and unique endoscope-assisted surgical management.

We report on the presentation, diagnosis, and surgical management of a rare symptomatic case of ecchordosis physaliphora, including the use of endoscopy as a valuable imaging device in its operative management. A 49-year-old male presented with a intradural extra-axial mass located to the left of the basilar artery in the prepontine space. The tumor was exposed via a transmaxillary transclival approach and resected under binocular microscopic visualization. Prior to and following resection, endoscopes were introduced into the surgical field to conduct anatomic surveys of the region and to assess the completeness of tumor removal. Ecchordosis physaliphora is an uncommon benign lesion originating from embryonic notochordal remnants. It rarely causes clinical symptoms due to its slow growth patterns. Although similarities between EP of the spheno-occiput and chordomas of the clivus make distinction obscure, differentiation is important. Differences in these lesions impact upon patient prognosis as well as therapeutic strategies. The use of endoscopy in the resection of this mass marks an innovative approach to intraoperative imaging of the clival region; improved visualization of the prepontine area allows for more accurate defintion of the surgical anatomy of the tumor and for thorough assessment of the completeness of tumor removal.

A dedicated craniofacial trauma team improves efficiency and reduces cost.

BACKGROUND: In this era of limited medical resources there is ever increasing pressure to lower costs, while preserving high-quality patient care. A dedicated craniofacial and skull base trauma team (SBT) was established at our Level I trauma center in July 1998. Previously, a rotating call panel of multiple private surgical subspecialists consulted on trauma patients with craniofacial or skull base injuries (Pre-SBT). This study was designed to assess the impact a dedicated craniofacial and skull base trauma team has on the cost and quality of patient care. MATERIALS AND METHODS: A retrospective review of the trauma registry and charts was performed including all craniofacial and skull base trauma cases in the 18 months Pre-SBT and 18 months following the establishment of a SBT. RESULTS: During the Pre-SBT period there were 29 craniofacial and skull base operations, whereas 28 such cases were performed by the SBT. The age, sex, injury severity score (ISS), mechanism of injury, and type of craniofacial/skull base injuries were comparable between groups. The SBT group demonstrated a reduction in the number of patients transferred to other institutions for definitive care (7 vs 1, P = 0.05) and statistically significant reduction in the number of subspecialty consultations (2.4 vs 1.3), time to operation (7.5 vs 3.0 days), and length of hospitalization (11.8 vs 6.8, all with P

Retained foreign body in the orbit and cavernous sinus with delayed presentation of superior orbital fissure syndrome: case report.

Reports of delayed onset of neurological symptoms after penetrating intracranial trauma are rare. We present the case of a patient who presented with superior orbital fissure syndrome 72 hours after reported trauma to the right eye. Subsequent workup revealed a foreign body located within the orbit, passing through the superior orbital fissure and into cavernous sinus, impinging on the right cavernous carotid artery. Evidence of an intraorbital abscess was also present. Surgical management consisted of a combination of frontopterional and orbital approaches to fully expose both the cavernous sinus and the orbital contents. The foreign body was removed and the abscess was drained. The carotid artery was found to be intact. At 10-month follow-up examination, a slight ptosis and medial gaze of the right eye persist. All other symptoms have resolved.

Asymptomatic renal neoplasms in the rectal cancer patient.

Although cancers of the rectum and kidney are common malignancies the incidence of coexistent rectal and renal primary tumors is unclear. Our objective was to determine the true incidence of synchronous neoplasms of the rectum and kidney. The computed tumor registry database at the City of Hope National Medical Center was queried for patients with synchronous rectal cancer and renal neoplasms presenting between August 1990 and August 2000. During the 10-year period there were 182 patients presenting for treatment of rectal carcinoma. Of these seven (3.8%) were found to have an asymptomatic renal neoplasm. Four patients underwent synchronous resection. Three patients underwent staged renal and rectal resections. The pathology of the renal lesions included renal cell carcinoma in six and an oncocytoma in one patient. Rectal lesions were all adenocarcinomas and all were within 10 cm of the dentate line. Three patients required abdominoperineal resections and four were treated with low anterior resections. Two patients presented with hepatic metastasis at the time of diagnosis. Five patients remain free of disease. Two patients died of persistent and recurrent disease 6 months and 40 months after operation. With the exception of one patient who required prolonged intubation because of severe Parkinson's disease there were no major complications after simultaneous resection of both renal and rectal disease. Simultaneous asymptomatic renal neoplasms may be found in up to 3.8 per cent of patients with rectal cancer. Synchronous lesions may be treated simultaneously without significant morbidity.

Assessment of the efficacy of endoscopy in pituitary adenoma resection.

OBJECTIVE: To obtain objective evidence that the use of endoscopy in the surgical management of pituitary tumors improves intraoperative visualization and significantly impacts operative outcomes. DESIGN: Case series of pituitary adenomas treated surgically by endoscope-assisted microscopic resection. SETTING: University-affiliated tertiary care medical center. PATIENTS: Consecutive sample of 9 patients referred for surgical management of pituitary adenoma. INTERVENTIONS: Each patient underwent transseptal transsphenoidal microscopic tumor resection. The procedure was modified by the use of intrasellar endoscopy as an adjunctive imaging modality. Following complete microscopic resection of tumor, rigid 0 degrees and 30 degrees 4.0-mm endoscopes were used to conduct a final survey of the sellar and parasellar spaces. Residual tumor fragments identified during this endoscopic examination were removed. OUTCOME MEASURES: Endoscopes were thought to have a significant impact on surgical therapy in cases where residual tumor that was not detected microscopically was identified and removed during endoscopic examination. Analysis of each case included correlation between intraoperative findings and retrospective review of dictated operative reports and intraoperative videotape. RESULTS: Three of the patients with macroadenoma (33% of total, 43% of macroadenoma cases) had tumor fragments that were only identified and removed endoscopically. CONCLUSIONS: Endoscopy provides distinct advantages over microscopy in imaging intrasellar and parasellar structures during pituitary tumor resection. These data support the numerous anecdotal accounts of the usefulness of pituitary endoscopy and are consistent with the small amount of objective evidence offered on the subject. Arch Otolaryngol Head Neck Surg. 2000;126:1487-1490

Pituitary lymphoma: a case report and literature review.

We report the case of a B-cell type pituitary lymphoma in a 65 year-old male immunocompetent patient who presented with hypogonadotropic hypogonadism and central hypothyroidism and subsequently developed pulmonary lymphoma. Only three cases of pituitary lymphoma have been previously reported, one in a patient with acquired immunodeficiency syndrome, one case of T-cell lymphoma reported in the Japanese literature, and one case of B-cell lymphoma. The previously reported immunocompetent patients presented with signs and symptoms of optic chiasm compression as contrasted to our patient's endocrinologic presentation. B-cell lymphoma of the pituitary gland is a exceedingly rare though distinct clinical entity.

Endoscope-assisted microvascular decompression of the trigeminal nerve.

Twenty-one patients with classic symptoms of trigeminal neuralgia underwent microvascular decompression of the trigeminal nerve through a retrosigmoid approach to the cerebellopontine angle. Endoscopy was used as an adjunctive imaging modality to microscopy. Specifically, endoscopes were used to confirm nerve-vessel conflicts identified by the microscope and to reveal others that escaped microscopic survey. Endoscopes were also used to assess the adequacy of the decompression performed microscopically. A total of 51 nerve-vessel conflicts were identified and treated, 14 of which were discovered only after endoscopy. Additionally, in 5 patients endoscopic examination of the surgical intervention demonstrated that further maneuvers were required to completely decompress the nerve. These results highlight the value of endoscopy in the diagnosis and therapy of cranial nerve pathology in the posterior fossa.

Cerebellopontine angle metastasis from papillary carcinoma of the thyroid: case report and literature review.

BACKGROUND: Papillary thyroid carcinoma is the most common type of well-differentiated thyroid malignancy and typically has an excellent prognosis and a low incidence of distant metastasis. However, once metastasis has developed in a distant site, prognosis is markedly diminished. Brain metastases from papillary thyroid carcinoma are extremely rare. Currently, there are no established therapeutic guidelines for treating brain metastases from thyroid carcinoma. CASE DESCRIPTION: We report on the case of a patient who presented with worsening neurological symptoms 3 years after resection of a thyroid papillary carcinoma. Magnetic resonance imaging identified a lesion of the cerebellopontine angle that encased the lower cranial nerves. The patient underwent a left retrosigmoid craniotomy with a 98% resection of the mass and received postoperative adjuvant radioiodine therapy, external beam radiation, and Gamma Knife radiosurgery. The patient tolerated the procedure well and demonstrated significant progressive improvement in her neurological symptoms postoperatively. After the multimodal approach to therapy, she remains symptom-free at 3-year follow-up. Radiographic monitoring of the small tumor remnant reveals a decrease in size from the postoperative period. CONCLUSION: This article is the first formal case report of cerebellopontine angle metastasis from papillary thyroid carcinoma. Therapeutic protocols for brain metastases of papillary thyroid carcinoma are not firmly established. This case illustrates the unique event of a cerebellopontine angle metastasis from papillary thyroid carcinoma, which was successfully treated with a combination of surgical, chemical, and radiological modalities. This aggressive course of therapy has resulted in an excellent outcome in this instance.

Endoscopic transglabellar approach to the anterior fossa and paranasal sinuses.

Historically, surgical management of tumors of the anterior cranial fossa with extension to the paranasal sinuses has been problematic. Wide exposure of these lesions has traditionally called for prolonged retraction of the frontal lobes or potentially disfiguring transfacial approaches, subjecting patients to undesirable neurological and cosmetic morbidity. With the introduction of progressively less invasive procedures, however, intracranial tumors with craniofacial involvement have become amenable to en bloc resection with a minimum of deleterious consequences. Increasing experience with endoscopy as an imaging modality in intracranial and extracranial surgery has led to the adaptation of endoscopic techniques to this setting. We have used an entirely endoscopic transglabellar approach to the anterior fossa to resect suprasellar tumors in two patients. The use of endoscopy allowed thorough visualization of all critical structures at the paramedian skull base without the need for a bicoronal scalp flap, bifrontal osteotomies, or brain retraction. Both lesions were resected in their entirety with no perioperative complications and with acceptable cosmetic results. These cases demonstrate how the application of endoscopy to surgery of the anterior skull base and craniofacial skeleton can eliminate the need for excessively invasive techniques without compromising surgical success.

Congenital teratoma of the oropharyngeal cavity with intracranial extension: case report and literature review.

Congenital teratoma of the oropharyngeal cavity is a unique clinical entity that poses immediate threats to the neonate in the postpartum period. Establishment of a secure airway is a primary goal after delivery; complete surgical resection is the subsequent guiding principle of management. Even more rare than teratomas confined to the oropharynx are tumors that extend into the intracranial cavity during development. Descriptions of these lesions in the medical literature are uncommon. In the majority of these reports, the tumors are associated with stillbirth, perinatal death, or significant morbidity after attempted resection. We present the rare case of a patient with congenital oropharyngeal teratoma with intracranial extension who has demonstrated long-term survival without any neurological or functional deficits. A unique delayed staged approach to resection of the extracranial and intracranial components of the tumor is described.

Endoscopic skull base surgery I: a new animal model for pituitary surgery.

Endoscopy has emerged as a new means to perform minimally invasive surgery of the skull base. Specifically, endoscopic techniques and instruments can be used to safely and effectively approach and resect tumors of the pituitary gland in humans. No animal model currently exists to serve as a template upon which to refine and develop endoscopic surgical technique in this region of the anatomy. We operated on two purpose-bred Hampshire-Yorkshire-Duroc hybrid swine to demonstrate the application of endoscopy to pituitary surgery. Based upon similar anatomical relationships in humans and swine between the oropharynx, nasopharynx, and skull base, we used a transoral, transpalatal approach to access the vomer of the swine. Under endoscopic exposure, we resected the vomer, entered the sphenoid sinus, and then resected the sphenoid septum, sella turcica, and adenohypophysis. Clear visualization of the pituitary, hypophyseal stalk, cavernous sinuses, and carotid prominences was achieved and documented with digital photography. Benefits and limitations of the technique were noted. These results have pertinent implications both for the study of the surgical anatomy of the swine craniofacial skeleton, and for future development of endoscopic surgical manipulation of the skull base.

Combined infratemporal fossa and transfacial approach to excising massive tumors.

Massive tumors of the infratemporal and pterygopalatine fossa are usually resected via the Fisch type C infratemporal fossa approach. This approach provides the surgeon with wide enough access to safely remove massive tumors, and it allows excellent control of the internal carotid artery without leaving facial scars. The disadvantages of this approach include a total loss of hearing on the affected side and the risk of damage to the facial nerve. The Fisch type D infratemporal preauricular approach provides a limited access to tumors, but it does preserve hearing. We studied the practice of combining the Fisch type D approach with a transfacial, transmaxillary approach. This allows the removal of massive tumors of the area without the necessity of resorting to the type C approach and the resultant loss of hearing and the possibility of facial paralysis. The flexibility of the type D infratemporal fossa approach allows the surgeon to combine it with transmaxillary, transmandibular, and periorbital approaches to remove tumors of all sizes from the infratemporal fossa, pterygopalatine fossa, parapharyngeal space, and orbit.

Endoscopic pituitary surgery: an in vivo model for transnasal transsphenoidal hypophysectomy.

The transseptal transsphenoidal approach to surgical intervention of the pituitary gland has been described for decades. Its gradual acceptance as the standard of therapy is indicative of general trends toward less invasive means of managing intracranial surgical disease. The evolution of the technique has coincided with advances in medical technology, including the introductions of intraoperative fluoroscopy and operative microscopy. Current progress in the field of endoscopy promises to further this evolution: endoscopic telescopes and instruments have improved on the optical and technical limitations of the microscope and require an even less invasive approach to the sella. To test the benefits and limitations of the endoscope in performing transnasal transsphenoidal hypophysectomy in an in vivo model, we operated on two live anesthetized pigs using 4.0-mm 0- and 30-degree 18-cm long endoscopes. The long lengths of the pig snouts precluded a transnasal approach to the sella; however, we were able to use the endoscopes to explore the sphenoid sinus, sella turcica, and parasellar regions via a transoral exposure. Digital images of the relevant skull base anatomy were captured. The benefits and limitations of the technique were noted and compared with our experience with microscopy in transsphenoidal hypophysectomy in humans.

Endoscopic skull base surgery II: a new animal model for surgery of the posterior fossa.

The field of skull base surgery has been influenced by a general philosophy that currently exists in modern surgical practice favoring less invasive means of managing surgical disease. Adapting techniques developed by general surgeons and other surgical subspecialists, skull base surgeons are now experimenting with endoscopy to resect tumors, manage vascular lesions, and manipulate critical intracranial structures. Lesions formerly requiring significant soft tissue dissection and craniotomy for exposure are now potentially amenable to treatment via a keyhole approach. As in other surgical specialties, however, a reliable animal model is necessary for experimentation with and development of new endoscopic techniques in the skull base. The swine provides just such a model, primarily due to craniofacial and skull base relationships that are analogous to humans. We have focused on the posterior skull base of the swine in this experiment: Via a retrosigmoid craniotomy we opened the dura of the posterior fossa and used endoscopes to visualize and manipulate the critical structures in this area. The cerebellum and midbrain were appreciated, as were cranial nerves V, VII, VIII, IX, X, and XI. Blood vessels on the surface of the midbrain were also identified. This experience further supports the use of the swine as an appropriate animal model for endoscopic skull base surgery.

Obstetrical factors governing the etiopathogenesis of lambdoid synostosis.

Lambdoid synostosis results in skull deformities of varying degrees characterized by occipital flattening over the involved suture and other compensatory changes in skull shape. Such changes include contralateral occipital bossing, contralateral frontal flattening, ipsilateral frontal bossing, and ipsilateral anteroinferior displacement of the pinna (ear shearing). These deformities tend to worsen during the first year of life. The etiology has been attributed to genetic factors and primary disorders of bone growth, in addition to secondary effects of other diseases and modulators of the in utero environment. To determine causal factors in the development of lambdoid synostosis, the authors reviewed medical records of the mothers of 13 children with lambdoid synostosis who were treated at the University Medical Center of the State University of New York at Stony Brook. Pre- and perinatal events, prior obstetrical, gynecological, medical, social, and family histories were considered. Births of normal infants immediately prior to and just after the affected babies were born were selected as controls. There is a significant association between increased duration of the first stage of labor and the development of lambdoid synostosis. Furthermore, our results indicate that this condition has a predilection toward male infants, and may be associated with preterm labor.

Traumatic thrombophlebitis of the superficial dorsal vein of the penis: an occupational hazard.

Several cases of thrombophlebitis of the superficial dorsal vein of the penis (TSDVP) have been reported in the literature. Etiologies may include any of the following: trauma associated with vigorous sexual intercourse; penile strangulation caused by a multitude of entities; penile injection; infection; neoplasm; or surgery. We report a rare case of traumatic TSDVP in a cab driver following repeated injury to the penis by a coin-filled pouch. We review the etiologies, mechanism, and treatment of traumatic TSDVP, and attempt to identify men who may be at similar occupational risk.