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Chapter 9
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9.1 Indications 86
Transcribriform
Approach
9.2 Surgical Steps 86
9.3 Case Example 88
9.4 Complications 89
9.5 Tips and Tricks 91
Transcribriform Approach
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9 Transcribriform Approach
Cristobal Langdon, Mauricio López Chacón, Manuel Bernal-Sprekelsen, Isam Alobid
Introduction
The transcribriform endonasal approach has become
an important surgical tool for the treatment of sinonasal and anterior skull base malignancies. Although
rare, the most common tumors of the anterior cranial
base in the region of the cribriform plate include
adenocarcinoma, squamous cell carcinoma, esthesioneuroblastoma, olfactory nerve schwannomas, and
olfactory groove meningiomas. The cribriform plate
encompasses the areas of the olfactory cleft, the skull
base above the ethmoid plate (septum), and the floor of
the olfactory bulbs. Experience with endoscopic techniques in sinus surgery has demonstrated that anterior
skull base is accessible in its full anteroposterior extent
(posterior wall of frontal sinus to planum sphenoidale)
and lateral extent (lamina papyracea). Recent reports of
the endonasal transcribriform approach have demonstrated good oncologic and functional results in the
treatment of anterior skull base tumors.
9.1 Indications
• Cerebrospinal fluid (CSF) leaks of the anterior skull base.
• Mucoceles.
• Large osteomas.
• Encephaloceles.
• Meningoceles.
• Olfactory groove meningiomas.
• Olfactory neuroblastoma.
• Sinonasal malignancy with anterior skull base invasion.
9.2 Surgical Steps
The transcribriform approach encompasses the medial
anterior skull base and olfactory groove. Intracranially, it
corresponds to the gyri recti, orbitofrontal gyri, olfactory
nerves, and interhemispheric fissure. The most important
vital structures related to this approach are the orbits laterally and the anterior cerebral arteries (second segment
of the anterior cerebral artery, A2) and their branches
(fronto-orbital, frontopolar) (Fig. 9.1). Depending on the
localization and/or size of the lesion, the approach can be
tailored to prevent unnecessary opening of the skull base.
Its anterior limits are the frontoethmoidal recess, but
could be extended up to the anterior plate of the frontal bone. Posteriorly, the limit is the planum sphenoidale
and/or the posterior ethmoidal arteries (PEAs). In a sagittal cut of a cadaveric specimen, we can observe the measures of the skull base structures and sagittal limits of the
approach (Fig. 9.2). Laterally, it is bound by the roof of the
ethmoid sinus (fovea ethmoidalis) and the medial orbital
wall (lamina papyracea). In general terms, this approach
is performed bilaterally; however, in some localized paramedian tumors, a unilateral approach with intention to
preserve contralateral olfaction is an option.
The initial step begins with anterior and posterior
ethmoidectomy with a wide sphenoidotomy to have a
complete access to the skull base (Fig. 9.3); the latter is
discussed in previous chapters. Usually, all expanded approaches begin with accessing the sphenoid sinus, which
sometimes may be difficult as the tumor precludes a clear
access or the bony structures are destroyed because of
the tumor infiltration. If this is the case, our philosophy
a
Fig. 9.1 Important branches of the internal carotid artery in relation to the transcribriform approach (cadaveric preparation). ACA,
anterior cerebral artery; AcoA, anterior communicating artery; AEA, anterior ethmoidal artery; CG, crista galli; CP, cribriform plate;
FOA, fronto-orbital artery; FPA, frontopolar artery; FS, frontal sinus; ICA, internal carotid artery; LP, lamina papyracea; OB, olfactory
bulb; ON, optic nerve; OphA, ophthalmic artery; OQ, optic chiasm; PEA, posterior ethmoidal artery; PS, planum sphenoidale.
86
ACA
ICA
ACoA
OQ
FOA
FPA
OphA
FPA
FOA
OB
AEA
CG
LP
b
CP
AEA
LP
FS
PEA
Sella
PS
ICA
7-8 mm*
ON
10-12 mm*
Transcribriform Approach
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Fig. 9.2 Sagittal cut of a cadaveric
specimen. Observe the sagittal
bony landmarks of the approach
a
*
d
GR
b
OB
C
ICA
S
and vascular structures. a, distance
between the anterior and posterior wall
of the frontal sinus (12.65 mm; range,
7–21.3 mm) (Lang and Haas 1979)1;
b, measurement of the cribriform
plate (24.7 mm; range, 11.5–32.8
mm) (Lang and Haas 1979); c, planum
sphenoidale (14.19 mm; range,
6.1–23.6 mm) (Lang and Haas 1979);
d, height from fl oor of the nasal cavity
to skull base (45.73 mm; range, 38–52
mm) (Lang and Baumeinster 1982).2
GR, gyrus recti; ICA, internal carotid
artery; OB, olfactory bulb; S, sphenoid
sinus.
FS
AEA
LP
PEA
PS
Fig. 9.3 Wide exposure for the transcribriform approach in
a cadaveric specimen. AEA, anterior ethmoidal artery (clipped
and transected); FS, frontal sinus; LP, lamina papyracea; PEA,
posterior ethmoidal artery; PS, planum sphenoidale.
AEA
LP
PEA
is to first access the bony landmarks and, if not, recognize
the vascular landmarks such as the anterior ethmoidal
arteries (AEAs) and PEAs.
It is important to enable a bimanual dissection. The
ability to use both hands (traditionally with suction in
the nondominant hand and a drill, dissector, or elevator
in the dominant hand) allows a clear operative field for
a safe dissection. We usually use angulated endoscopes
(30 or 45 degrees) during the approach depending on the
surgeon preferences.
On behalf of an easier explanation, the approach will be
described step-by-step starting from the sphenoid up to
the frontal sinus.
9.2.1 First Step
Bilateral sphenoidotomies are performed, and the planum sphenoidale is exposed. It is convenient to extend
laterally to the level of the medial pterygoid plates to
ensure adequate exposure, not only for visualization
but also to warrant unobstructed access in the event of
critical bleeding. The posterior septal artery should be
preserved in case a pedicled nasoseptal flap is required
for skull base reconstruction. A posterior septectomy is
performed to facilitate the use of multiple instruments
simultaneously.
9.2.2 Second Step
Complete ethmoidectomies are performed bilaterally.
Identification of the AEA and PEA on both sides (see
Chapter 7) and their cauterization or clipping under
direct visualization prevent uncontrolled bleeding and
contribute to early tumor devascularization.
runs in an anteromedial direction through the anterior
ethmoidal canal, which is usually located between the
second and third lamella, posterior to the frontal recess.
The PEA courses horizontally in the posterior ethmoidal canal, usually located 10 to 12 mm from the AEA,
7 to 8 mm from the optic foramen, and 18 mm from the
tuberculum sella.
5,6
At this point, one should have completed the exposure to the anterior cranial base from the
posterior aspect of the frontal sinus to the planum sphenoidale and laterally to the lamina papyracea bilaterally.
If additional anterior exposure is needed, it can be obtained by a frontal recess approach, with medial widening of the frontal recesses and removal of the frontal
nasal septum and inferior frontal sinus septum (in the
sense of a Draf type III).
3,4
The AEA
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9.2.3 Third Step
Opening of the cribriform plate and dura is performed
(Figs. 9.4a,b and 9.5). Drilling proceeds from the frontal recess or posterior table of the frontal sinus working
posteriorly. Removal and cauterization of the soft tissue
overlying the bone of the olfactory sulcus will help in
drilling. As the crista galli is approached, a significant
drilling is required as it is attached to the falx and an
eggshell bone is required to remove it without damage.
The dissection is performed posteriorly until complete
exposure of the dura is obtained. Now the dura can be
coagulated to provide additional hemostasis and tumor
devascularization. The dura is then incised and opened
FS
CG
AEA
LP
on both sides of the falx to prevent damaging the anterior
falcine artery and associated falcine branches (supplying
the tumor and falx) as they run in the midline. One must
remember that this artery is the primary residual feeding
vessel for meningiomas. In these cases, once the meningioma is exposed, internal debulking can continue until
the edge of the falx and the anterior falcine artery vessels
are identified and coagulated for final tumor devascularization and hemostasis. In case the tumor extension
reaches the orbit, it is advisable to first detach the dura
from the supraorbital aspect before its incision, as this
is helpful not only for the later over and underlay reconstruction, but also for potential enlargement of margins
along the dura.
FS
LP
LP
PEA
a b
Fig. 9.4 (a) Cadaveric specimen. Opening of the cribriform plate, note the en-bloc drilling of the cribriform plate from the frontal
sinus to the planum sphenoidale. In some cases, it can be drilled in an eggshell fashion, leaving a thin bony layer and then removing
it with a Freer or Cottle dissector. (b) Live surgery. Transcribriform approach, en-bloc drilling of the cribriform plate. AEA, anterior
ethmoidal artery; CG, crista galli; FS, frontal sinus; LP, lamina papyracea; PEA, posterior ethmoidal artery; PS, planum sphenoidale.
White arrows indicate cauterized anterior ethmoidal arteries.
PS
PS
Finally, reconstruction of the skull base is of utmost
CG
FS
importance to prevent complications, mostly related to
postoperative CSF leakage. We usually use multilayer re-
AEA
LP
FL
LP
PEA
construction between the dura and the surrounding bone
to provide a watertight closure. Then a vascularized mucosal flap is used to cover the skull base reconstruction
and the previously denuded surrounding bone.
9.3 Case Example
A 22-year-old healthy man with history of sharp and
ON
CAs
Sella
CApc
Clivus
Fig. 9.5 Transcribriform approach completed. AEA, anterior
ethmoidal artery; CApc, paraclival carotid artery; CAs,
parasellar carotid artery; CG, crista galli; FL, frontal lobe; FS,
frontal sinus; LP, lamina papyracea; ON, optic nerve; PEA,
posterior ethmoidal artery.
severe stabbing headache at the right fronto-orbitary
aspect presents at the neurologic clinic. Magnetic
resonance imaging (MRI) showed a mass in the olfactory fossa extending to the fronto-ethmoidal region
(Figs. 9.6–9.9). The intracranial extension revealed contrast enhancement of the dura without cerebral involvement (Kadish stage C). Endoscopic biopsy was positive for
olfactory neuroblastoma, and a transcribriform approach
was performed (Figs. 9.10–9.14).
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Fig. 9.6 Contrast MRI (axial plane). Tumor with contrast
enhancement involving the fronto-ethmoidal region and
medial wall of the right orbit (without involvement of the
medial rectus muscle).
Fig. 9.8 Contrast MRI (sagittal plane). Tumor involving the
right anterior skull base, olfactory fossa, and frontal sinus.
Notice the displacement of the right frontal lobe (gyrus recti)
without any sign of parenchymal infi ltration.
Fig. 9.7 Contrast MRI (coronal plane). Tumor involving the
right anterior skull base, olfactory fossa, and frontal sinus.
T
S
MT
Fig. 9.9 Endonasal endoscopic view (45 degrees) of
the tumor. MT, middle turbinate; S, septum; T, olfactory
neuroblastoma tumor.
9.4 Complications
The relative incidence of these complications is related to
the tumor location/extension and the subsequent defect
left after its removal. Major complications include postoperative CSF leakage with or without concurrent meningitis, pneumocephalus, seizures, strokes, intracranial
hematoma, intracranial abscess, orbital hematoma, and
death. The best way to prevent or reduce complications is
to make a thorough plan of your surgery and be ahead of
any nuance or problem.
Postoperative CSF leak is a common complication,
but recently many endoscopic skull base surgeons have
shown the feasibility and efficacy of endoscopic repair
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FS
LP
Fig. 9.10 Transcribriform approach, endonasal endoscopic
view (45 degrees). AEA, anterior ethmoidal artery; FS, frontal
sinus; LP, lamina papyracea; PS, planum sphenoidale; psCA,
parasellar carotid artery; S, sella turcica.
AEA
psCA
PS
psCA
S
FS
LP
LP
Fig. 9.11 Transcribriform approach, endonasal endoscopic
view (45 degrees), opening of the cribriform plates. Right
olfactory bulb and dura were resected. AEA, anterior ethmoidal
artery; FS, frontal sinus; LP, lamina papyracea; OB, left olfactory
bulb; PS, planum sphenoidale.
AEA
LP
OB
PS
FL
FOA
OB
Fig. 9.12 Olfactory fossa. Note the preserved left olfactory
bulb (OB) and in the back the fronto-orbital artery (FOA).
FL, frontal lobe.
FS
F
Fig. 9.13 The fi rst layer of the skull base reconstruction was
fascia lata (F). FS, frontal sinus.
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Transcribriform Approach
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for large skull base defects with mucoperichondrial/mucoperiosteal vascularized flaps. The nasoseptal mucosal
flap for skull base reconstruction has reduced the overall
postoperative CSF leakage rate
fails or the pathology involves the nasal septum, then the
lateral wall flaps with anterior or posterior pedicles can
be used. The most important factor in decreasing postoperative CSF leak during anterior skull base defect repair is obtaining a watertight dural closure. The use of
a lumbar drainage in this situation is still controversial.
Nevertheless, the authors believe that its use decreases
intracranial pressure and reduces pressure on the site
of repair, thereby preventing leakage. Other authors believe that CSF drainage through the lumbar spine may
elevate the brain off the anterior skull base, thus pulling
the reconstruction of the skull base inwards.
of the latter theory also claim that downward pressure
of the frontal lobe will theoretically assist in sealing the
closure, and that possible air aspiration via an anterior
cranial defect may predispose patients to pneumocephalus and subsequent brain herniation. Tension pneumocephalus usually occurs as a result of a ball-valve effect
from a small defect in the repair coupled with improper
lumbar drain usage. We recommend lumbar drain usage
and meticulous repair to prevent this life-threatening
complication. Treatment depends on the patient’s neurologic status. The main treatment consists of clamping
the lumbar drain and applying intravenous antibiotics.
Frequent neurologic evaluation and serial head computed tomography scanning of patients without neurologic
changes are scheduled.9 In patients with acute neurologic
changes, immediate decompression is warranted in addition to those previously listed. In the rare event of a seizure, treatment consists of intravenous administration of
one of the different types of anticonvulsants and airway
protection in the acute setting. Strokes after endoscopic
anterior skull base resection are rare.
Intracranial hematoma may happen when hemostasis
during and at the end of the procedure was not meticulous. The anterior cerebral arteries are within the field of
dissection during the intracranial tumor resection. Care
should be taken to prevent excessive torsion or pulling on
tumor adjacent to these vessels because this may cause
bleeding from main trunks or its branches. In revision
cases with marked fibrosis and tissue adhesion, an open
7
down to 5.4%. If this flap
8
Supporters
approach should be considered if tumor cannot safely be
dissected from the vessels endoscopically. To protect adjacent neural tissue, bipolar cautery, instead of monopolar,
is recommended for achieving hemostasis. If an intracranial hematoma is discovered postoperatively, treatment
consists of drainage with control of hemorrhage (often no
specific source is found) and prescription of prophylactic
antibiotics to prevent meningitis or intracranial abscess.
Intracranial abscess can occur after any type of skull
base procedures. A common source is CSF leakage leading to meningitis and eventual abscess formation. The use
of a perioperative intravenous antibiotic that crosses the
blood–brain barrier is endorsed to decrease the risk.
Although uncommon, all patients undergoing anterior
skull base surgeries should be advised of the possibility
of a fatal complication. Without timely recognition and
appropriate medical or surgical management, any of the
previously discussed complications can quickly evolve
and lead to a preventable fatality.
3
9.5 Tips and Tricks
• Localize frontal sinuses and both AEA and PEA and the
planum sphenoidale as a first step to secure a wide and
accessible approach.
• Perform a Draf type III procedure to have a wide anteri-
or margin to work with.
• Devascularize the tumor by cauterizing or clipping
both AEA and PEA before entering the intracranially.
• Open the dura on both sides of the falx to prevent dam-
aging the anterior falcine artery and associated falcine
branches (supplying the tumor and falx) as they run in
the midline.
• In cases the tumor grows laterally toward the supra-
orbital dura, first detach the dura there before open-
ing it as it will be helpful to obtain further margins for
potential frozen sections and to reconstruct the skull
base defect.
• Angled scopes facilitate and secure a complete dissec-
tion of the tumor as all cavities can be explored.
• Study the skull base reconstruction you may need be-
fore starting surgery. Be sure that you can use vascular-
ized flaps for the reconstruction and evaluate alterna-
tive types of reconstruction.
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Transcribriform Approach
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ITF
a
Fig. 9.14 Final reconstruction
for the transcribriform approach.
(a) A free inferior turbinate fl ap
(ITF) was used to cover the defect
after underlay reconstruction
with lyophilized fascia lata.
(b) T1 MRI sequence sagittal and
(c) coronal views showing the
fi nal reconstruction 3 months
postsurgery.
ITF
b
c
References
1. Lang J., Haas R. Neue Befunde zur Bodenregion der Fossa cranialis
anterior. Verh Anat Ges. 1979;73:77–79
2. Lang J, Baumeister R. Postnatal growth of the nasal cavity. Gegenbaurs Morphol Jahrb. 1982;128(3):354–393
3. Kasam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded
endonasal approach: the rostrocaudal axis. Part I. Crista galli to
the sella turcica. Neurosurg Focus 2005;19(1):E3
4. Batra PS, Kanowitz SJ, Luong A. Anatomical and technical correlates in endoscopic anterior skull base surgery: a cadaveric analysis. Otolaryngol Head Neck Surg 2010;142(6):827–831
5. de Notaris M, Esposito I, Cavallo LM, et al. Endoscopic endonasal
approach to the ethmoidal planum: anatomic study. Neurosurg
Rev 2008;31(3):309–317
ITF
6. Erdogmus S, Govsa F. The anatomic landmarks of ethmoidal arteries for the surgical approaches. J Craniofac Surg
2006;17(2):280–285
7. Kassam AB, Thomas A, Carrau RL, et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap.
Neurosurgery 2008;63(1, Suppl 1):ONS44–ONS52, discussion
ONS52–ONS53
8. Anand VK, Schwartz TH. Surgical approaches to the anterior
skull base. In: Anand VK, Schwartz TH, eds. Practical Endoscopic Skull Base Surgery. San Diego, CA: Plural Publishing Inc;
2007:71–88
9. Enseñat J, de Notaris M, Sanchez M, et al. Endoscopic endonasal surgery for skull base tumours: technique and preliminary results in a consecutive case series report. Rhinology
2013;51(1):37–46
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0
0
Chapter 10
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10.1 Technical Description 94
Endoscopic
Transtuberculum
Transplanum Approach
10.2 Case Example 102
Endoscopic Transtuberculum Transplanum Approach
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10 Endoscopic Transtuberculum
Transplanum Approach
Kumar Abhinav, Juan C. Fernandez-Miranda
Introduction
In this chapter, we present the technical nuances for
performing the endoscopic endonasal transtuberculum
transplanum approach in a stepwise manner using illustrations derived from dissection of the anatomic specimens. This is then supplemented with a clinical case
example.
Using our own experience and recently published
findings from a research study, we will also present the
nuances for performing a 270-degree decompression of
the optic canal (OC) and the opening of the dural sheath
surrounding it, which may be required for invasion/
involvement of the OC with pathologies such as tuberculum sellae meningioma. This endoscopic endonasal
approach has been successfully employed for the removal
of tuberculum sellae and planum sphenoidale meningiomas. The incidence of optic canal invasion (OCI) has
been reported to be high with these tumors, ranging from
approximately 56 to 77%, thus highlighting the need for
the appreciation of the anatomy of the OC and its surrounding structures from an endonasal perspective.
Planum
Limbus
Op. prom.
The knowledge of the anatomy and the principles involved in the dural opening and exposure can also be
applied for approaching suprasellar lesions such as craniopharyngioma where the dura of chiasmatic sulcus is
opened to expose the suprasellar infrachiasmatic cistern
and resect the lesion.
10.1 Technical Description
Endoscopic endonasal anatomic dissections is
performed using rod lens endoscopes (Karl Storz, 4 mm,
18 cm, Hopkins II, 0 and 45 degrees) attached to a highdefinition camera and a digital video recorder system.
Heads are positioned supine on the dissection table
with a Mayfield head holder being used to maintain a
neutral position.
An endoscopic endonasal approach to the sella and
tuberculum sellae region involves a wide bilateral sphenoidotomy, posterior ethmoidectomy, and posterior
septectomy (Fig. 10.1). The intrasphenoidal septations
are thinned down using a drill while keeping in mind
Fig. 10.1 Intrasphenoidal landmarks
can be seen including the lateral
opticocarotid recess (LOCR), limbus,
and optic canal prominence (Op.
prom.) with its thin bony medial
wall intact. Clinoidal segment
of the carotid artery (Clin. car.)
inferomedial to the LOCR can be
seen. Bony structure overlying the
planum sphenoidale (planum) is also
visualized.
Clin. car.
94
LOCR
Sella
CR
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