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Neurosurgery

Expanded Endoscopic Endonasal Approach For treating skull-base tumors

10/25/2010

PUP-EndoscopicEndonasalUCLA Expanded Endoscopic Endonasal Approach to Skull-Base Tumors

Many tumors, including meningiomas, craniopharyngiomas, pituitary tumors, clival chordomas, nasal tumors, and chondrosarcomas, occur at or near the midline of the skull base, which extends from just above the bridge of the nose to the upper part of the cervical spine. Over the past decade, breakthroughs in surgical techniques and technology have allowed surgeons to remove many of these tumors using an endoscopic approach that is performed using the natural pathway of the nasal cavity — without need for an incision. Specially trained UCLA surgeons are at the forefront of using the endoscope to safely and effectively remove tumors that until recently would have required large, open procedures. In many cases, open craniotomy procedures that require long scalp incisions and retraction of the brain, and potentially disfiguring or debilitating open facial or transoral operations, can be avoided.

EEEA Skull-Base Surgery

UCLA surgeons are now routinely performing endonasal tumor resections using the expanded endoscopic endonasal approach (EEEA), a revolutionary technique with the benefit of greatly improved visualization and freedom of movement that allows precise, bi-manual microsurgery. With superior illumination and remarkable magnification combined with a much wider field of view, UCLA surgeons are able to confidently and precisely remove tumors near the midline of the skull base. UCLA was one of the first centers in the Western U.S. to offer this revolutionary surgical technique.

UCLA operating rooms are custom equipped with high-definition video systems that provide super-high-resolution, highly magnified views of the surgical field that were not possible a decade ago. The effective utilization of this technology, however, requires extensive experience and expertise with endoscopic techniques. A team approach, combining the knowledge and skills of a head and neck surgeon with that of a neurosurgeon, provides many advantages over a single-surgeon technique and has enhanced UCLA’s ability to perform EEEA tumor resection.

PUP-MeningiomaAdvantages of the Expanded Endoscopic Endonasal Approach

Most neurosurgeons offering endonasal approaches for intracranial tumors perform the procedure using a speculum. The speculum, a cylindrical tube placed in the nose through which the surgeon works, limits the surgeon’s view because the device’s opening is only about one centimeter wide. Instruments that are passed through the speculum can block the surgeon’s view. More importantly, the view is limited to the area directly in front of the speculum — so the surgeon is unable to visualize tumor tissue that lies outside this viewing area. Removal of some tumor tissue must be done blindly, greatly increasing the chances of leaving residual tumor or causing injury to arteries, cranial nerves and even the brain.

The expanded endoscopic endonasal approach has revolutionized skull-base surgery by eliminating the need for a speculum. By carefully drilling away a larger opening in the anterior wall of the sphenoid sinus, UCLA endoscopic surgeons create a wide working space that allows surgical exposure of the entire tumor. The head and neck surgeon and neurosurgeon work together to access the tumor, remove it and repair the opening.

How the New Technique is Performed

PUP-EndoNasal TechniqueThe UCLA team works closely together during the EEEA procedure. The head and neck surgeon first gains access to the sphenoid sinus, an air-filled cavity centered in the skull base. Bone is removed to completely expose the tumor region, increasing the probability of complete removal.

During the tumor resection, the head and neck surgeon maintains the endoscopic view on the area of interest, leaving the neurosurgeon free to use both hands to perform microsurgical manipulation of the tissue. Although these tumors are deep within the head, the EEEA allows essentially the same microsurgical techniques used in open craniotomy without the need for a head incision. Special angled-lens endoscopes allow the neurosurgeon to literally look and work around corners, further enhancing the probability of complete tumor removal and reducing complications.

Once tumor removal is complete, the skull-base defect created by the EEEA exposure requires specialized reconstruction to facilitate healing and reduce the risk of cerebrospinal fluid leaks. A nasoseptal mucosal flap with an intact blood supply, elevated at the beginning of the procedure, can be used to cover the exposed surgical resection. Because it is vascularized, living tissue, the nasoseptal flap quickly heals, sealing the area and restoring normal nasal function.

Participating Physicians

Neurosurgery

Marvin Bergsneider, M.D.
Director, UCLA Benign Skull-Base and Pituitary Tumor Program
Professor and Vice Chair of Clinical Affairs

Neil Martin, M.D.
Professor and Chair, UCLA Department of Neurosurgery

Head and Neck Surgery

Marilene Wang, M.D.
Professor, Endoscopic Skull-Base Surgery and Rhinology

Jeffrey Suh, M.D.
Assistant Professor, Endoscopic Skull-Base Surgery and Rhinology

UCLA Neurosurgery

Box 956901
Los Angeles, CA 90095-6901
Phone (310) 825-5111
Fax (310) 825-7245
Email LVillarreal@mednet.ucla.edu
www.pituitary.ucla.edu





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