Endoscopic surgery of skull base chordomas.

Objective To assess our clinical experience in treating midline intracranial pathology using minimally invasive surgical techniques. Design Retrospective chart review of patients undergoing endoscopic endonasal resection of clival chordomas. Setting Two tertiary referral centers in Australia and New Zealand. Main Outcome Measures Patients were assessed by intraoperative findings (macroscopic resection rate, tumor size, and operative complications) and clinical outcomes (residual disease, postoperative complications, recurrence rate, and mortality). Results Fourteen patients underwent endoscopic resection of clival chordomas (seven primary, seven revision) with a mean follow-up of 41.45 months (3 to 104 months). Macroscopic resection rates were 71% and 29%, respectively. Mean operative time was 386 minutes. Overall cerebrospinal fluid (CSF) leak rate was 3/14 (21%) and, using the nasoseptal flap, it was 0/5 (0%). Two patients developed late recurrence; one died of disease and one was treated with intensity modulated radiation therapy. Overall mortality was 2/14 (14%). Conclusion Endoscopic resection of clival chordomas is a safe and viable alternative to the traditional open approach. The nasoseptal flap is an excellent method of obtaining a watertight skull base closure. Furthermore, this series highlighted the fact that the primary attempt at surgery offers the best chance to achieve a total resection.

Surgical outcomes of endoscopic management of adenocarcinoma of the sinonasal cavity.

OBJECTIVE: To report the surgical outcomes of endoscopic resection of adenocarcinomas of the Sinonasal cavity. METHODS: Retrospective chart review of patients presenting with adenocarcinoma of the anterior skull base between 1998-2008. All patients who underwent wholly endoscopic resection were included in the study. RESULTS: Twelve patients presented with adenocarcinoma involving the sino-nasal cavity. At diagnosis 6 patients were staged as a T2, 5 as a T3 and one as a T4. All of the patients had successful removal of the tumour entirely endoscopically. Three patients recurred: 2 locally and 1 with distant metastases. Overall, 11 patients are alive and free of disease and 1 patient dead of disease. We found an overall disease free survival rate and overall survival rate of 91.6%. The follow-up period ranged from 10 to 96 months with a median of 30 months. CONCLUSION: Endoscopic management of adenocarcinoma of the sino-nasal cavity can be a viable treatment option to craniofacial resection. With the advancement in endoscopic equipment and surgeon skill, larger tumours may be managed wholly endoscopically.

Endoscopic management of frontal sinus osteomas revisited.

BACKGROUND: Recent articles have published guidelines regarding the role of endoscopic surgery in the removal of frontal sinus osteomas. These guidelines recommend the endoscopic approach for small osteomas but recommend an osteoplastic flap for larger tumors. This study presents a series of endoscopically resected tumors both large and small. METHODS: Retrospective chart reviews were performed. Charts were reviewed of all patients who underwent surgical resection of a frontal sinus osteoma from 1998 to 2008. Sinus CT scans were reviewed and each tumor was staged according to Kennedy's grading system proposed in 2005. RESULTS: Twenty-three patients, 8 with a grade IV tumor, 6 with a grade III tumor, and the remaining with a grade I or II tumor, underwent endoscopic resection of a frontal sinus osteoma. In 15 patients a modified Lothrop procedure was performed for tumor removal. In addition, a blepharoplasty incision was used in one patient for removal of a large orbital extension of the tumor and another underwent an enlarged frontal sinus trephine performed via a browline incision. In the remaining patients a frontal sinusotomy with minitrephination provided enough access for tumor removal. Over an average follow-up of 36 months no recurrences were noted. Symptoms improved in all but one patient. There were no postoperative complications. CONCLUSION: Endoscopic resection of both large and small frontal sinus osteomas is feasible. In this article we have shown successful removal of large osteomas that fill the entire frontal sinus with the modified Lothrop procedure.

Otolaryngologic heuristics: a rhinologic perspective.

Rhinological heuristics are adapted from common principles within the field of otolaryngology. The most important principle in achieving quality endoscopic sinus surgery is good haemostatic control of the surgical field. Once this is achieved, the surgeon can then begin advancing to other heuristic principles. Thinking one to two moves in advance allows the surgeon to take advantage of the many dually purposed instruments available. Learning to visualize buried structures by their subtle projections quickly follows. Finally, an ergonomically positioned surgeon with intricate anatomical knowledge of the sinonasal cavities permits a second surgeon to assist and greatly expand the limit of what is possible.