Traditional endonasal and microscopic sinus surgery complications versus endoscopic sinus surgery complications: a meta-analysis.

The aim of this study was to compare the incidence of complications of endoscopic sinus surgery (ESS) to the incidence of complications of traditional and microscopic sinus surgery. A meta-analysis was carried out on 28 series of patients (a total of 13,405) who had undergone ESS, 8 series of patients (3,887 in total) who had undergone traditional endonasal sinus surgery and 7 series of patients (1,630 in total) who had undergone microscopic sinus surgery. The authors used the Bayesian inference package WinBUGS operating from within the statistical computer program R (version 2.7.1). Major complications had a higher incidence after traditional sinus surgery than ESS but this fact did not cause a significant statistical difference, whereas microscopic surgery had significantly more complications than ESS (p < 0.05). Carrying out our meta-analytic study, comparing major and minor complications of endonasal surgical approaches, was very difficult due to several methodological biases of data extraction and evaluation from studies concerning a broad timespan. Regarding major complications, we only found a significant statistical difference (p < 0.05) between the endoscopic (1%) and the microscopic methods (2.0%), but, if we had analyzed the data considering the natural learning curve of the latest ESS surgical approach, and if we had not considered the results produced in the first 10 years (1988-1998) concerning ESS in our meta-analysis, we would have found a statistically significant difference (p < 0.05) between the endoscopic (0.4%) and the traditional (1.1%) approach as well.

Técnicas hemostáticas en la endoneurocirugía / Hemostatic technique during endoneurosurgery

La creciente popularidad de la neurocirugía mínimamente invasiva ha llevado al desarrollo de abordajes ampliados para el tratamiento de las lesiones de base de cráneo. Uno de los desafíos mayores para conseguir una resección completa de los tumores con la máxima seguridad, especialmente en las lesiones intradurales, es obtener una hemostasia efectiva. En los últimos 10 años, los autores han desarrollado progresivamente un abordaje sistematizado para controlar esta dificultad. Ello ha requerido el desarrollo de nuevos instrumentos, así como variaciones en la técnica estándar. En este artículo se presentan la técnica y la evolución de la hemostasia endoneuroquirúrgica (AU)

The growing popularity of minimally invasive surgery has led to the development of extended approaches for the treatment of skull base lesions. One of the major challenges in achieving complete tumoral resection while guaranteeing maximum patient safety, especially in intradural lesions, is to obtain effective hemostasis. In the last 10 years the authors have progressively developed a systematic approach to control this difficulty. This has required the development of new instruments as well as variations to the standard technique. The present article describes the technique and development of endoneurosurgical hemostasis (AU)

Complicaciones en cirugia endoscópica de la base de cráneo / Complications of endoscopic skull base surgery

Las complicaciones mayores asociadas a los abordajes endoscópicos no son distintas de las asociadas a los abordajes tradicionales de la base de cráneo. Las más frecuentes son la fístula de líquido cefalorraquídeo (LCR), neumoencefalocele a tensión, sangrado perioperatorio, accidentes cerebrovasculares y, más raramente, complicaciones infecciosas, osteorradionecrosis. Estas complicaciones pueden ser debidas a errores técnicos, errores de valoración, fallos tecnológicos o a la aparición de un problema insospechado. En el artículo se exponen las posibles complicaciones y su solución. Se hace especial hincapié en la reconstrucción de la base de cráneo y se describe el colgajo nasoseptal de Hadad-Bassagasteguy como un avance muy significativo en la resolución de las fístulas de LCR postoperatorias (AU)

Major complications associated with endoscopic approaches are the same as those associated with traditional skull base approaches. The most frequent are cerebrospinal fluid leaks, tension pneumocephalus, bleeding, cerebrovascular accidents and, more rarely, infectious complications and osteoradionecrosis. These complications may be caused by technical errors, deficient assessment, technical failure or unexpected problems. The present article describes the possible complications and their solutions. Special emphasis is placed on skull base reconstruction and the Hadad-Bassagasteguy naso-septal flap as a major advance in the resolution of postoperative cerebrospinal fluid leaks (AU)

Abordajes endonasales endoscópicos ampliados a la base de cráneo caudoventral / Endoscopic Expanded Endonasal Approaches to the Caudo-Ventral Skull Base

Los abordajes transesfenoidales se han usado en el último siglo para la resección de tumores hipofisarios u otros tumores sellares. Recientemente los abordajes endonasales estándar se han ampliado para proporcionar acceso a otras lesiones parasellares. Con la incorporación de los endoscopios, esta expansión tiene un potencial muy importante para la resección de las lesiones de la base de cráneo. Se revisan y se presentan los puntos de referencia anatómicos y las técnicas quirúrgicas empleadas en los abordajes endoscópicos ampliados a la región sellar, el clivus y la unión cervicomedular, acompañadas de ilustraciones de los casos descritos. La región sellar, la porción caudal de la base anterior de cráneo medial y la unión cervicomedular se han dividido en módulos para su abordaje: sellar, transellar, subsellar, tercio medio de clivus, su tercio inferior y la unión cervicomedular. Se proponen módulos de aprendizaje y progresión en la técnica quirúrgica para alcanzar los niveles adecuados de entrenamiento para poder acceder, con garantías, a las lesiones y regiones descritas. Los abordajes endoscópicos ampliados son factibles y reúnen un gran potencial para disminuir la morbilidad. Se debe evaluar críticamente la efectividad y el uso apropiado de la técnica y hacer un estrecho seguimiento de la evolución de los casos según vayan aumentando en los años venideros (AU)

Transsphenoidal approaches were used in the last century to resect pituitary or other sellar tumors. Recently, standard endonasal approaches have been extended to provide access to other parasellar lesions. With the incorporation of endoscopes, this expansion is potentially of great importance in the resection of skull base lesions. The anatomical reference points and the surgical techniques used in extended endoscopic approaches to the sellar region, clivus and cervico-medullary junction are reviewed and illustrations from the cases described are provided. The sellar region, the caudal portion of the medial anterior skull base and the cervico-medullary junction have been divided into modules for their approach: sellar, transellar, subsellar, middle third of the clivus, lower third of the clivus and the cervico-medullary junction. Dedicated courses and a progressive escalation of surgical case complexity are the keys to adequate training to achieve safe access to the lesions and regions described. Extended endoscopic approaches are feasible and will potentially reduce morbidity. The effectiveness and appropriate use of this technique should be critically evaluated. As the technique becomes more widely used, patient outcomes should be closely followed-up (AU)

Cirugía de la base anterior de cráneo / Anterior Cranial Base Surgery

La cirugía de base de cráneo anterior es un escenario idóneo para la cooperación entre el otorrinolaringólogo y el neurocirujano. Hay una amplia variedad de neoplasias que pueden afectar a esta región. La endoscopia endonasal puede proporcionar una vía de acceso adicional a estas lesiones, sea de forma aislada o combinada con abordajes externos. Este artículo pretende sentar las bases de la técnica endoscópica en la base de cráneo anterior. Se describen los criterios para la selección de pacientes, las pruebas complementarias necesarias (olfatometría, tomografía computarizada, resonancia magnética, angiografía) y la preparación preoperatoria, y se detalla la técnica endoscópica, con la descripción de la anatomía y los puntos de referencia más importantes. La reconstrucción del defecto creado se realiza con diversos materiales y colgajos para conseguir una reducción de la tasa de fístulas de líquido cefalorraquídeo que, en la actualidad, es menor del 5% gracias al colgajo de Hadad-Bassagasteguy. El abordaje endoscópico de la base de cráneo anterior es posible y supone un gran potencial para disminuir la morbilidad. Se debe evaluar la eficacia y el uso adecuado de estas técnicas mediante el estrecho seguimiento de las series de casos que se realicen de ahora en adelante (AU)

Surgery of the anterior skull base is the ideal scenario for collaboration between otorhinolaryngologists and neurosurgeons. A wide variety of neoplasms can occur in this region. Endonasal endoscopes can provide an additional route of access to these lesions, whether alone or combined with external approaches. The present article aims to describe the main principles of endoscopic skull base surgery. The criteria for patient selection and the complementary investigations required (olfactometry, computed tomography, magnetic resonance imaging, angiography), preoperative planning, and the endoscopic technique are described. The anatomy of the region and the most important landmarks are also described. Reconstruction of the resulting defect is performed using diverse materials and flaps to reduce cerebrospinal fluid leak rates, which are currently less than 5% after the Hadad-Bassagasteguy flap. Endoscopic anterior skull base surgery is feasible and provides the possibility of reducing morbidity. The effectiveness and appropriate use of these techniques should be evaluated through close follow-up of the series of cases that undergo this approach from now onwards (AU)

Abordajes endoscópicos endonasales transpterigoideos / The Endoscopic Endonasal Transpterygoid Approach

En otorrinolaringología, la cirugía endoscópica nasosinusal se ha convertido en el tratamiento estándar para las enfermedades inflamatorias y neoplásicas. La colaboración con el neurocirujano ha hecho posible avanzar en la resección de tumores sellares y parasellares. La existencia de ópticas anguladas y la aparición de nuevos instrumentos han hecho asequibles regiones como la fosa pterigopalatina e infratemporal por vía endonasal. El tercio medio del clivus y la región alrededor de la carótida interna intrapetrosa son áreas de difícil acceso en la base de cráneo. El artículo describe y sistematiza los abordajes transpterigoideos. Se describen los requisitos preoperatorios, las indicaciones y contraindicaciones, así como los requisitos necesarios para estos abordajes. Se clasifican los abordajes infrapetrosos y suprapetrosos, subdivididos en cinco zonas: ápex petroso medial, unión petroclival, seno cavernoso inferior, seno cavernoso superior y fosa infratemporal/fosa media. Se hace hincapié en la sistematización del abordaje mediante la creación de un espacio cuadrangular cuyos límites son: los segmentos horizontal y vertical de la carótida interna, V2, la duramadre de la fosa media y el VI par craneal, que permite el acceso a la punta de peñasco y a la región lateral del seno cavernoso. Los abordajes endoscópicos constituyen una buena alternativa para la resección de algunas lesiones que afectan al ápex petroso, la unión petroclival, el seno cavernoso,la fosa infratemporal y la fosa craneal media, siempre y cuando sean mediales a los elementos neurovasculares de la región (AU)

In otorhinolaryngology, endoscopic sinus surgery has become the standard treatment for inflammatory and neoplastic disease. Collaboration with neurosurgeons has allowed new advances in the resection of sellar and parasellar tumors. The existence of angled endoscopes and the development of new instruments have provided access to regions such as the pterygopalatine and infratemporal fossae through the endonasal route. The middle third of the clivus and the region surrounding the petrous internal carotid artery is an area of the skull base that is difficult to reach. The present article describes and classifies the transpterygoid approach. Preoperative requirements, indications and contraindications and the requisites for this approach are discussed. The infrapetrous and suprapetrous approaches are classified and subdivided in five areas: 1) medial petrous apex, 2) petroclival junction, 3) inferior cavernous sinus, 4) superior cavernous sinus, and 5) inferior cavernous sinus. Emphasis is placed on classification of the approach through the creation of a quadrangular space with the following borders: the horizontal and vertical segments of the internal carotid artery, V2, the middle fossa dura mater and cranial nerve VI, which allows access to the petrous apex and the lateral region of the cavernous sinus. Endoscopic approaches constitute a valid alternative for the resection of lesions affecting the petrous apex, petroclival junction, cavernous sinus, infratemporal and the middle cranial fossae, so long as these lesions lie medial to neurovascular structures in the region (AU)

Endoscopic dacryocystorhinostomy: modified technique.

BACKGROUND: Dacryocystorhinostomy (DCR) is a surgical technique that has been increasingly used by otolaryngologists in recent years due to the improved endonasal approach with endoscopes. Although it was first described in 1893 by Caldwell, it has been performed by ophthalmologists. OBJECTIVES: Even though permeability results are similar in long-term follow-up, we present some modifications that in our opinion contribute to the improvement of the results and the simplification of the surgical technique: mucosal flap design that helps to improve the postoperative mucosal recovery, careful dissection of the bony suture between the frontal process of the maxillary bone and the lacrimal bone, and osteotomy using a Smith-Kerrison forceps. STUDY DESIGN AND SETTING: Two groups are compared. In the first group (96 DCRs), patients underwent chisel osteotomies without a mucosal flap of the lacrimal duct, and in the second group (40 DCRs), the modified technique was applied. RESULTS: Final permeability results are similar (92.7% versus 87.5%). No major complications were found, and the most common minor complication was postoperative eyelid hematoma in cases where orbital fat was exposed (5 cases versus 7 cases). CONCLUSIONS: There are no differences in final results, but the modified technique is easier to perform, improves postoperative mucosal recovery, is more functional and less aggressive, and improves the cost-benefit ratio.