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Endoscopic Transplanum and Sellar Approach

Introduction ▪ Endoscopic approaches to intracranial tumors of the planum and sella are increasingly prevalent secondary to improved panoramic visualization, improved tumor resection, increased working angles, and decreased intranasal complications. ▪ Approaches to the sphenoid planum and sella turcica require an understanding of the anatomic relationships of the sphenoid sinus, optic nerve, carotid artery, sella, planum, and clivus. ▪ Intracranial dissection requires knowledge and experience of…

Endoscopic Resection of Pituitary Tumors

Introduction ▪ The endoscopic resection of sellar and suprasellar tumors involves access to the sella via dissection through the sphenoid sinus. ▪ These procedures are often done in a combined operation with both a neurosurgeon and otolaryngologist and thus employ a two-surgeon technique. ▪ In this approach, the otolaryngology team provides the “pathway” and the neurosurgery team resects the tumor, with visualization provided by the otolaryngologist.…

Sphenoid Sinus Cerebrospinal Fluid Leak and Encephalocele Repair

Introduction ▪ Dandy, in 1926, was the first to report a transcranial technique for the closure of a cerebrospinal fluid (CSF) leak using a fascia lata graft. ▪ Open approaches were associated with morbidities, including seizures, memory deficits, and intracranial hemorrhage. ▪ Dohlman pioneered an extracranial technique in 1948 with success rates approaching 80%. ▪ The first transeptal and fully endonasal approaches were introduced by Hirsch…

Repair of Cerebrospinal Fluid Leak and Encephalocele of the Cribriform Plate

Introduction ▪ Cerebrospinal fluid (CSF) rhinorrhea originating near the cribriform plate results from the breakdown of barriers separating the subarachnoid space and the paranasal sinuses. This may result from traumatic, iatrogenic, neoplastic, congenital, and inflammatory processes. ▪ A CSF leak in the cribriform region may also be spontaneous in nature and may present with a meningoencephalocele, which is the herniation of the anterior cranial fossa soft…

Endoscopic Craniofacial Resection

Introduction ▪ Endoscopic craniofacial resection (CFR) has emerged as an alternative to the traditional CFR originally credited to Ketcham in 1963. ▪ The standard craniofacial approach for tumor resection combines a transfacial approach via a lateral rhinotomy or midface degloving to gain access for removal of the sinus component of the tumor with a transcranial approach to remove the skull base and intracranial portion of the…

Pterygopalatine/Pterygomaxillary Space Approaches, Maxillary Artery Ligation, and Approach to Juvenile Nasopharyngeal Angiofibroma

Introduction ▪ Pterygopalatine/pterygomaxillary space (PPS) approaches are used to treat lesions in areas posterior to the maxillary sinus, including the pterygopalatine fossa and lateral recess of the sphenoid sinus (LSR). Pathologic processes within the PPS are rare; the most common ones are juvenile nasopharyngeal angiofibroma (JNA), neurogenic tumors such as schwannoma, and perineural extension of sinonasal malignancy. A characteristic lesion found within the LSR is the…

Endoscopic Vidian Neurectomy

Introduction ▪ Vidian neurectomy has been performed to relieve the symptoms of vasomotor rhinitis since the 1960s after being introduced by Golding-Wood as a transantral procedure. ▪ Transnasal endoscopic vidian neurectomy was introduced by Kamel and Zaher and later refined by many, including El Shazly, El-Guindy, and Robinson and Wormald. ▪ Better understanding of the anatomy with improving imaging modalities and better visualization of the operative…

Endoscopic Denker Approach for Anterior Maxilla Tumors

Introduction ▪ Despite recent advances in endoscopic techniques, tumors involving the anterior maxilla remain difficult to reach through a purely endonasal approach. ▪ Even with cross-court procedures, lesions involving the anteroinferior and anterolateral corners of the maxillary sinus may be inaccessible endoscopically. ▪ Sublabial incisions with canine fossa puncture or a Caldwell-Luc approach are often still necessary for surgical removal of anteriorly based maxillary pathology. ▪…

Endoscopic Medial Maxillectomy

Introduction ▪ Medial maxillectomy is a procedure historically used for the removal of benign and low-grade malignant tumors of the medial aspect of the maxilla, lateral nasal wall, ethmoid sinuses along the lamina papyracea, and the lacrimal sac. ▪ The endoscopic approach allows superior illumination and magnification as well as the ability to treat diseases that extend beyond the limits of the traditional external medial maxillectomy.…

Endoscopic Approach and Removal of Orbital Tumors

Introduction ▪ The endoscopic transnasal approach to the orbit is indicated for tumors located medially and/or inferiorly to the optic nerve. ▪ This anatomic site is deep, poorly illuminated, and obscured by orbital fat when approached through a standard external approach. ▪ Globe and optic nerve manipulation required for external access are also avoided using the endoscopic approach. Anatomy ▪ The extraconal space consists primarily of…

Optic Nerve Decompression

Introduction ▪ Endoscopic transnasal surgery has become an effective approach to the surgical management of diseases of the sinuses, orbit, and anterior skull base. Technologic advances have been critical in advancing endoscopic surgical procedures, with the introduction of improved optics and lighting, advanced instrumentation, and image-guided surgical navigation. ▪ Multiple approaches to the optic nerve have been described, ranging from endonasal endoscopic to open craniotomy. The…

Endoscopic Orbital Decompression

Introduction ▪ For more than 100 years, surgical decompression of the orbit has been used to treat severe proptosis and optic neuropathy associated with Graves disease, also known as Thyroid Eye Disease (TED). ▪ Although decompression techniques involving removal of each of the four walls of the orbit had been described, the transantral approach reported by Walsh and Ogura in the 1950s had been favored by…

Endoscopic Dacryocystorhinostomy

Introduction ▪ Endoscopic dacryocystorhinostomy (DCR) is a well-established treatment for epiphora caused by anatomic or functional obstruction of the nasolacrimal apparatus. ▪ A thorough understanding of the endonasal anatomy, wide marsupialization of the lacrimal sac, and meticulous care of the mucosa are critical for success. Anatomy ▪ The lacrimal sac extends approximately 10 mm above the axilla of the middle turbinate. ▪ The common canaliculus opens…

Extended Sphenoid Sinus Antrostomy and Radical Sphenoidectomy

Introduction ▪ Endoscopic sphenoidotomy has become the most common surgical approach for management of inflammatory and neoplastic diseases of the sphenoid sinus largely due to its excellent outcomes and low morbidity. ▪ Long-term outcomes of endoscopic sphenoidotomy in the context of isolated sphenoid sinus disease (ISSD) have demonstrated patency rates of greater than 90% at a follow-up of up to 4 years. ▪ However, chronic rhinosinusitis…

Modified Medial Maxillectomy for Recalcitrant Maxillary Sinusitis

Introduction ▪ The modified medial maxillectomy entails removing a large portion of the medial maxillary wall to gain wide access to the maxillary sinus. It is primarily used for the removal of benign tumors, such as inverted papillomas and juvenile nasopharyngeal angiofibromas. ▪ The modified medial maxillectomy can also be used to treat chronic maxillary sinusitis refractory to maximum medical management and standard maxillary antrostomy. Modified…

Revision Functional Endoscopic Sinus Surgery: Completion Sphenoethmoidectomy

Introduction ▪ Completion sphenoethmoidectomy refers to a revision sinus procedure in a patient in whom a maxillary antrostomy and partial ethmoidectomy have been previously performed. ▪ Patients with nasal polyposis and moderate to severe inflammatory disease commonly have persistent symptoms despite a partial ethmoidectomy and limited sinus surgery. Completion sphenoethmoidectomy is often combined with a frontal recess dissection in hopes that it will be the last…

Balloon Dilatation of the Maxillary, Frontal, and Sphenoid Sinuses

Introduction ▪ Balloon sinus dilatation is a surgical technique that widens the natural sinus ostium using a balloon catheter. ▪ Balloon sinus dilatation has been used to address the maxillary, sphenoid, and frontal sinuses. It can be performed as a balloon-only procedure unaccompanied by endoscopic sinus surgery (ESS) in which the sinus ostia are dilated without any removal of bone or redundant mucosa. It can also…

Postoperative Débridement

Introduction ▪ For many, postoperative débridement is considered a crucial aspect of optimizing endoscopic surgical results. ▪ The most widely cited study supporting the practice of postoperative débridement is that of Senior et al., which suggested that weekly postoperative débridement was integral to the long-term improvement of symptoms in their series. ▪ Several advantages to postoperative débridement have been described: – Impairment of mucociliary function persists for…

Frontal Sinusotomy—Draf III

Endoscopic Common Frontal Sinusotomy Introduction ▪ The common frontal sinusotomy, modified endoscopic Lothrop procedure (MELP), or Draf III procedure, is an adaptation of the technique first described by Dr. Harold Lothrop in 1914. Wolfgang Draf popularized the operation in the 1990s; it has since become an important surgical procedure used in the treatment of a variety of disease processes. ▪ The fundamental concept of the common…

Frontal Sinusotomy—Draf IIb

Introduction ▪ Endoscopic sinus and skull base surgery has become an effective part of the management of chronic rhinosinusitis (CRS) and tumors of the sinuses and anterior skull base. Technologic advances have been critical in advancing endoscopic surgical procedures, with the introduction of improved optics and lighting, advanced instrumentation, and image-guided surgical navigation. Hemostatic materials and devices have similarly evolved to assist in the management of…