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Evolution of Skull Base Surgery: The Multidisciplinary Team Approach
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collaboration between rhinologists and neurosurgeons,
opening their minds.
Slowly but steadily, the modern endoscopic skull base
surgery was developed in some centers, not without controversies, particularly when malignant sinonasal tumors
were also started to be removed through an endoscopic
approach.
3
As always in medicine, this progression occurred
stepwise. First, small amenable tumors, and then, with
increasing experience, larger tumors were approached. Of
course, the idea to treat malignant tumors solely through
the nose was scary due to the narrow entrance to the surgical field, the difficulties to perform a “monoblock” resection, and last but not the least, the problems in achieving
tumor-free margins. This led some authors to debulking
or fragmenting (“disassembling”) the tumors.
term, endoscopic approaches seem to achieve similar outcomes and survival rates as open ones.
32–34
3
In the long
Technology is increasingly allowing the expansion of
the endoscopic nasal surgery, as is the number of rhinologists and neurosurgeons involved in endoscopic
multidisciplinary teams. High-definition cameras have
replaced traditional cameras. Furthermore, the advent
of high-definition monitors, translating into an increased
pixel density, offers the surgeon better color, contrast,
resolution, and peripheral visualization of the surgical
field.
This, together with the increasing experience of the
teams, particularly the groups from Pittsburgh (Kassam,
Carrau and coworkers) and Italy (Cappabianca, Castelnuovo and Locatelli, Frank and Pasquini), led to the development of different surgical corridors in the coronal and
sagittal planes, with the rule of never to cross nerves and/
or the internal carotid artery, and expanded the endonasal corridors, as can be studied in the different chapters of
this book, from the anterior skull base to the middle and
posterior cranial fossae.
The major challenge encountered was in reconstructing those large skull base defects left after extended
approaches. Postoperative CSF leakages, with the risk of
ascending bacterial meningitis subsequently increasing,
were among the most frequent complications feared. To
minimize that risk, the incorporation of pedicle flaps into
the armamentarium of skull base reconstruction can be
considered a milestone. The nasoseptal flap described by
Hadad et al in 2006 definitely opened the door to more
transnasal surgeries of the skull base, reducing the risk of
CSF leaks significantly.
35
Since then, other local nasal flaps
such as lateral wall flap and regional flaps, for example,
the pericranial flap, were extremely helpful to reconstruct even after endoscopic resections of large tumors.
The aim of this book is to recollect and thoroughly
describe all anatomic aspects and possibilities of transnasal endoscopic surgery of the paranasal sinus, as this
will serve to understand more extended approaches.
Here, important vascular structures, such as the ethmoidal arteries or the internal maxillary and sphenopalatine artery, plus its branches, deserve a chapter on
its own. The next block deals with the anterior cranial
fossa, analyzing all the different approaches to the anterior skull and brain, from the transcribriform to the transorbital approach, including also the sella and suprasella
spaces, and the cavernous sinus. We then move laterally
toward the middle cranial fossa, focusing on the quadrangular space, the intrapetrous artery, and the anterior
petrosectomy. The next group of chapters is related to the
clivus and posterior cranial fossa corridors, including the
retrosellar, the transclival, the craniovertebral junction,
the transcondylar, and the jugular foramen approaches.
After that, the approaches to the pterygopalatine and
infratemporal fossa are described, including the nasopharyngectomy. The last chapters address combined endoscopic and transcranial approaches, basic landmarks
in expanded endoscopic skull base surgery, particularly
bony landmarks and the internal carotid artery, and reconstruction techniques.
References
1. Nogueira JF Jr, Hermann DR, Américo RdosR, Barauna Filho IS,
Stamm AE, Pignatari SS. A brief history of otorhinolaryngolgy:
otology, laryngology and rhinology. Braz J Otorhinolaryngol
2007;73(5):693–703
2. Stammberger H. History of rhinology: anatomy of the paranasal
sinuses. Rhinology 1989;27(3):197–210
3. Castelnuovo P, Dallan I, Battaglia P, Bignami M. Endoscopic endonasal skull base surgery: past, present and future. Eur Arch Otorhinolaryngol 2010;267(5):649–663
4. Draf W, Michael P, Minovi A. History of endonasal tumor surgery.
In: Draf W, Carrau RL, Bockmuehl U, Kassam AB, Vajkoczy P, eds.
Endonasal Endoscopic Surgery of the Skull Base Tumors. Stuttgart:
Thieme; 2015:2–7
5. Aaron-Harris C. Dissertation on the Diseases of the Maxillary
Sinus. Philadelphia, PA: Lea & Blanchard; 1843
6. Caldwell GW. Disease of the accessory sinuses of the nose, and an
improved method of treatment for suppuration of the maxillary
antrum. N Y Med J 1893;58:526–528
7. Luc H. Une novelle methode operatoire pour la cure radicale et
rápida de lémpheme chronique du sinus maxillaire. Arch Laryngol
1897;6:275
8. Chandra RK, Conley DB, Kern RC. Evolution of the endoscope
and endoscopic sinus surgery. Otolaryngol Clin North Am
2009;42(5):747–752, vii
9. Heermann H. Endonasal surgery with utilization of the binocular microscope [in German]. Arch Ohren Nasen Kehlkopfheilkd
1958;171(2):295–297
10. Govindaraj S, Adappa ND, Kennedy DW. Endoscopic sinus surgery: evolution and technical innovations. J Laryngol Otol
2010;124(3):242–250
11. Grunert P, Gaab MR, Hellwig D, Oertel JM. German neuroendoscopy
above the skull base. Neurosurg Focus 2009;27(3):E7
12. Schneider CV. Libores de catarrhis. Wittenberg; 1660
13. Feldmann H. The maxillary sinus and its illness in the history of
rhinology. Images from the history of otorhinolaryngology, highlighted by instruments from the collection of the German Medical
History Museum in Ingolstadt [in German]. Laryngorhinootologie
1998;77(10):587–595
14. Golding-Wood PH. Observations on petrosal and vidian neurectomy in chronic vasomotor rhinitis. J Laryngol Otol. 1961
Mar;75:232–47
15. Messerklinger W. Endoscopy of the nose. Baltimore, MD: Urban &
Schwarzenberg; 1978
16. Stammberger H. Personal endoscopic operative technic for the lateral nasal wall—an endoscopic surgery concept in the treatment
of inflammatory diseases of the paranasal sinuses [in German].
Laryngol Rhinol Otol (Stuttg) 1985;64(11):559–566
17. Kennedy DW. Functional endoscopic sinus surgery. Technique.
Arch Otolaryngol 1985;111(10):643–649
18. Lund VJ, Lloyd GA. Radiological changes associated with benign
nasal polyps. J Laryngol Otol 1983;97(6):503–510
19. Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryngol Head
Neck Surg 1997;117(3, Pt 2):S35–S40
20. Setliff RC, Parsons DS. The “hummer”: new instrumentation for functional endoscopic sinus surgery. Am J Rhinol 1994;8(6):275–278
21. Anon JB, Lipman SP, Oppenheim D, Halt RA. Computer-assisted endoscopic sinus surgery. Laryngoscope 1994;104(7):901–905
22. Waitz G, Wigand ME. Endoscopic, endonasal removal of inverted
papillomas of the nose and paranasal sinuses [in German]. HNO
1990;38(7):242–246
23. Kamel RH. Transnasal endoscopic surgery in juvenile nasopharyngeal angiofibroma. J Laryngol Otol 1996;110(10):962–968
24. Bernal-Sprekelsen M, Vázquez AA, Pueyo J, Carbonell Casasús J.
Endoscopic resection of juvenile nasopharyngeal fibromas [in
German]. HNO 1998;46(2):172–174
25. Mitskavich MT, Carrau RL, Snyderman CH, Weissman JL, Fagan JJ.
Intranasal endoscopic excision of a juvenile angiofibroma. Auris
Nasus Larynx 1998;25(1):39–44
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Evolution of Skull Base Surgery: The Multidisciplinary Team Approach
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26. Langdon C, Herman P, Verillaud B, et al. Expanded endoscopic
endonasal surgery for advanced stage juvenile angiofibromas: a
retrospective multi-center study. Rhinology 2016;54(3):239–246
27. Wigand ME. Transnasal ethmoidectomy under endoscopical control. Rhinology 1981;19(1):7–15
28. Hardy J, Ciric IS. Selective anterior hypophysectomy in the treatment of diabetic retinopathy. A transsphenoidal microsurgical
technique. JAMA 1968;203(2):73–78
29. Jankowski R, Auque J, Simon C, Marchal JC, Hepner H, Wayoff M.
Endoscopic pituitary tumor surgery. Laryngoscope 1992;
102(2):198–202
30. Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 1997;87(1):44–51
31. Cappabianca P, de Divitiis O, Maiuri F. Evolution of transsphenoidal
surgery. In: de Divitiis E, Cappabianca P, eds. Endoscopic Endonasal Transsphenoidal Surgery. Vienna: Springer; 2003:1–8
32. Snyderman CH, Carrau RL, Kassam AB, et al. Endoscopic skull base
surgery: principles of endonasal oncological surgery. J Surg Oncol
2008;97(8):658–664
33. Nicolai P, Battaglia P, Bignami M, et al. Endoscopic surgery for malignant tumors of the sinonasal tract and adjacent skull base: a
10-year experience. Am J Rhinol 2008;22(3):308–316
34. Lund VJ, Stammberger H, Nicolai P, et al; European Rhinologic
Society Advisory Board on Endoscopic Techniques in the Management of Nose, Paranasal Sinus and Skull Base Tumours. European position paper on endoscopic management of tumours of
the nose, paranasal sinuses and skull base. Rhinol Suppl 2010;
(22):1–143
35. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal
approaches: vascular pedicle nasoseptal flap. Laryngoscope
2006;116(10):1882–1886
6
Chapter 2
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2.1 Surgical Simulation
Methodology 8
Three-Dimensional
Anatomy of the Skull
Base: The Ventral
Pathway
2.2 Simulation of the Different
Steps of the EE Approach 8
2.3 Conclusion 15
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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2 Three-Dimensional Anatomy of the Skull Base:
The Ventral Pathway
Alberto Prats-Galino, Matteo de Notaris, Marija Mavar Haramija, Juan Antonio Juanes Méndez, Joaquim Enseñat
Introduction
In recent years, advances in computer technology and
medical imaging techniques have acquired a significant
impact on different branches of surgery, medical education, and research. In the fields of neurosurgery and
otorhinolaryngology, progress in neuroimaging studies, such as high-resolution computed tomography (CT)
scans, magnetic resonance imaging studies, and digital
subtraction angiography data, has certainly refined the
visualization of anatomic structures within the brain and
the skull. At the same time, the evolution of minimally
invasive techniques and the introduction of the endoscope have led to endoscopic endonasal (EE) approaches
rapidly becoming the standard of care for pituitary and
other skull base tumors, thus requiring the acquisition of
new surgical skills. Even experienced neurosurgeons and
rhinologists face a steep learning curve in EE approaches, as the operation is performed through a tight space,
where both the lack of maneuverability and the conventional mucosal bleeding may hinder the visualization of
the surgical field. An additional burden is represented by
the lack of stereoscopic vision of most endoscopes. Even
though the advent of three-dimensional (3D) scopes in
endonasal surgery has improved depth perception, such
new tools still face difficulties in hand–eye coordination.
For such reasons, endoscopic transsphenoidal surgery
can take a long time to learn and execute, especially for
those surgeons not fully confident with the scope.
Anatomic cadaveric dissection has been, for many
years, the only training tool available for guiding the
improvement of technical skills in endoscopic transsphenoidal surgery. However, during the last decade, with the
diffusion of 3D computer-generated models that provide
accurate patient-specific 3D reconstructions from neuroimaging data, allowing interaction with such models,
and the simulation of the different steps of the surgical
intervention, the training in EE neurosurgery has gained
further developments.
Combined with anatomic laboratory dissection, 3D
computer-based reconstructions represent a unique
opportunity for research and educational purposes when
applied to the transsphenoidal perspective, guiding the
acquisition of specific visual information for endoscopic
approaches to the skull base.
helical acquisition protocol, with 0.625-mm slice thickness,
using a gantry angle of 0 degrees. The images obtained were
stored into the hospital PACS (Picture Archiving and Communication System) network in a DICOM (Digital Imaging
and Communications in Medicine) format.
2.1.2 Anatomic Cadaveric
Dissection
All dissections were performed in the Laboratory of Surgical NeuroAnatomy (LSNA), at the University of Barcelona,
Spain. The position of the head on the dissection table
was adjusted to match the usual position in the operating room, to better emulate a true surgical intervention.
An EE transsphenoidal approach to the midline skull base
was performed in three specimens using a rigid 0-degree
endoscope, 18 cm in length and 4 mm in diameter (Karl
Storz Endoscopy), as the sole visualizing instrument
during the whole procedure.
2.1.3 Image Processing: Generating
a Virtual 3D Model
The 3D model was developed from the CT scans of the
anatomic specimens (postdissection CT), using a specific
software for visualization and manipulation of biomedical data (Amira Visage Imaging Inc.). The 3D reconstructions of the bone volume of each surgical procedure were
compared with those obtained in the dissection laboratory. The methodology followed at the LSNA to generate the
3D models is described in detail elsewhere.
1–3
2.2 Simulation of the Diff erent
Steps of the EE Approach
In the present section, the main steps usually used to
reach the midline skull base through a ventral approach
are described. Specifically, the EE approach using different computer-based 3D models generated from the
high-resolution CT scans is modeled in a step-by-step
sequence, including the different nasal steps,
sphenoidal and extended approaches,
corridors to the ventral brainstem.
9,10
4,5
5–8
the trans-
and the surgical
2.1 Surgical Simulation
Methodology
2.1.1 Data Acquisition
(Predissection CT Scan)
A CT scan (SOMATOM Sensation 64; Siemens AG) of each
specimen was performed prior to each dissection at the
Department of Neuroradiology, Hospital Clinic, Barcelona.
The heads were positioned in the scanner according to the
Frankfurt plane. All studies were performed with a multislice
8
2.2.1 Nasal Steps
Once the endoscope is progressively introduced through
the nostrils, the nasal vestibule, and the piriform aperture,
a general view of the nasal cavity is obtained. The key nasal
structures to be identified include the nasal septum (S),
the head of the inferior (IT) and middle turbinates (MT),
and the respective inferior and middle meati (Fig. 2.1).
In a second step, a bilateral middle turbinectomy (MT,
triangulated models) is performed to allow a wide exposure (Fig. 2.2). Once both middle turbinates are removed,
the bulla ethmoidalis (BE, Fig. 2.3) is easily identified.
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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S
MT
IT
Fig. 2.1 General frontal view of the nasal cavity in a 3D model of the skull. For comparative purposes, an endoscopic view is added.
IT, inferior turbinate; MT, middle turbinate; S, nasal septum.
IT
MT
S
EC
Fig. 2.2 Bilateral middle turbinectomy step. The right part of the fi gure shows at higher magnifi cation a 3D model of the structures
to be removed (triangular models). EC, ethmoidal cells; IT, inferior turbinate; MT, middle turbinate; S, nasal septum.
S
MT
IT
MT
9
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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EC
S
BE
IT
Fig. 2.3 Septectomy step. The right part of the fi gure shows at higher magnifi cation a 3D model of the structure to be removed
(triangular model). BE, bulla ethmoidalis; EC, ethmoidal cells; IT, inferior turbinate; S, nasal septum.
In a third step, a septectomy is performed. This is
accomplished by the resection of the posterior part of the
nasal septum (S, triangulated model) (Fig. 2.3).
The removal of the nasal septum may require the disarticulation of the sphenoidal crest from the perpendicular
plate of ethmoid (Fig. 2.4).
In a fourth step, a bilateral ethmoidotomy is performed.
It is important to avoid damaging the lamina papyracea
(Fig. 2.5).
The final nasal step of the approach corresponds to
an anterior sphenoidotomy. Once the anterior wall of
the sphenoid is removed, several sphenoid septa can be
observed within the sphenoid sinus. These septa could
maintain a very close relationship with the internal carotid artery, so their removal must be performed very
carefully (Fig. 2.6).
and the clivus (C). Laterally, prominences corresponding to the optic nerve (OP), the internal carotid artery
(CP), the opticocarotid recess in between (OCR), and
the paraclival carotid prominence (CPc) can be found
(Fig. 2.7).
From the sphenoid sinus, different extended
approaches have been described to access different
compartments of the midline skull base. These include
the transcribiform (red), the transplanum/transtuberculum (pale blue), the sellar (yellow), the transclival
(dark blue), the craniovertebral junction (purple),
and the lateral cavernous sinus (green) approaches
(Fig. 2.8).
2.2.3 Surgical Corridors to the
Ventral Brainstem
2.2.2 Transsphenoidal and
Extended Approaches
Within the posterior wall of the sphenoid sinus, several
critical landmarks must be identified. At the midline,
the “suprasellar notch” can be seen or the tuberculum
sellae (TS) as viewed from below, the sellar floor (SF),
The transclival EE approach allows access to the ventral
and ventrolateral surfaces of the brainstem and related
cisternal through three anatomically defined subregions:
cranial (green box), middle (blue box), and caudal (yellow
box) levels. Each of these levels shows a close relationship
with standard surgical corridors established via the retrosigmoid route (Fig. 2.9).
10
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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S
MT
IT
MS
Fig. 2.4 Disarticulation of the posterior nasal septum. The right part of the fi gure shows at higher magnifi cation a 3D model of the
structure to be removed (triangular model). An axial CT section has been added as reference. Note that the anterior part of the nasal
septum is not removed. IT, inferior turbinate; MS, maxillary sinus; MT, middle turbinate; S, nasal septum.
Fig. 2.5 Bilateral ethmoidotomy step. The right part of the fi gure shows at higher magnifi cation a 3D model of the structure to be
removed (triangular model). An axial CT section has been added as reference. The lamina papyracea at the internal wall of the orbit
must be preserved (arrow). EC, ethmoidal cells; LP, lamina papyracea; MT, middle turbinate; S, nasal septum.
EC
MT
S
LP
11
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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Fig. 2.6 Anterior sphenoidotomy. Endonasal view of the anterior wall of the sphenoid (pink model, top left image) and of the
sphenoid sinus cavity after removing this wall (top right image). Reconstruction of both internal carotid arteries closely related with
the point of insertion of a sphenoid septum (yellow triangular model, bottom image), over an axial CT section. ICA, internal carotid
artery; MT, middle turbinate; S, nasal septum; SS, sphenoid sinus; ST, superior turbinate.
The cranial level is limited by a line joining the two
posterior clinoid processes superiorly and by a line joining both abducens nerves entering the dural porus inferiorly. Through this level, the ventral surface of the upper
brainstem (interpeduncular fossa), the basilar artery, the
superior cerebellar artery, the pre- and postcommunicating segments of the posterior cerebral arteries, the oculomotor nerve passing in between, and the abducens nerve
are visualized (Fig. 2.10).
The middle level is limited upward by the inferior
margin of the cranial level and downward by a line joining the intracranial openings of the hypoglossal canal.
Through this level, the entire ventral surface of the pons
12
and medulla oblongata, the basilar artery arising from
the two vertebral arteries as well as its pontine branches,
the anteroinferior cerebellar artery, the posteroinferior
cerebellar, the origin of the abducens nerve at the bulbopontine sulcus, the acoustic-facial nerve bundle, and the
IX–XI cranial nerves can be identified (Fig. 2.11).
Finally, the caudal level is bounded superiorly by the
middle level and inferiorly by the superior margin of C1.
Through this level, the hypoglossal nerve emerging from
the medulla, between the pyramid and the inferior olive,
the loop of the posteroinferior cerebellar artery, and the
accessory nerve rootlets entering the jugular foramen are
visualized (Fig. 2.12).
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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OP
OCR
CP
OP
OCR
CP
CPc
Fig. 2.7 Simulated anterior endoscopic view after a transsphenoidal approach (top). At bottom right, the 3D model is shown
at higher magnifi cation. The walls of the sphenoid sinus are represented with a semitransparent eff ect, to visualize the anatomic
structures located just posteriorly. At bottom left, a real endonasal endoscopic image of the posterior wall of sphenoid sinus is shown
for comparison purposes. The optic nerves and the internal carotid are reproduced as yellow and red tubular structures, respectively.
C, clivus; CP, carotid prominence; CPc, paraclival carotid prominence; OCR, opticocarotid recess; OP, optic prominence; SF, sellar
fl oor; TS, tuberculum sellae.
TS
SF
C
CPc
CP
OP
OCR
CPc
TS
SF
C
13
Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway
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Fig. 2.8 3D models of the diff erent extended EE approaches to the midline skull base and cavernous sinus as seen from endonasal
(left) and transcranial (right) perspectives. The optic nerves and the internal carotid are reproduced as yellow and red tubular
structures, respectively. Red, transcribiform approach; pale blue, transplanum/transtuberculum approach; yellow, sellar approach;
dark blue, transclival approach; purple, craniovertebral junction approach; green, cavernous sinus approach.
Ch
VA
SCA
III
ICAc
VI
dm
VA
C1
SCA
III
ICAc
BA
VI
FL
AICA
XII
Fig. 2.9 3D reconstruction of the three subregions (cranial, middle, and caudal) to gain access to the ventral and ventrolateral
brainstem surface, delimited by anatomic landmarks in the clival region using an endonasal endoscopic approach (left). The right
image shows a general endoscopic perspective from an endonasal view of these three subregions. AICA, anteroinferior cerebellar
artery; BA, basilar artery; Ch, chiasm; C1, atlas; dm, dura mater; FL, foramen lacerum; ICAc, clival segment of the internal carotid
artery; SCA, superior cerebellar artery; VA, vertebral artery; III, oculomotor nerve; VI, abducens nerve; XII, hypoglossal nerve.
FL
14
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