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The New Armenian Medical Journal Vol 11 2017 No 3 p 4 10 Mesropyan H B et al. ples with a tendency toward more aggressive in Technical advances in instrumentation and surgi. tervention As a result surgeons have excessive cal method have broadened the application of endo. freedom in the nose and the procedures are not scopic surgery to a wide variety of indications. standardized Wormald P 2005 Schulze S et al 2002 Kountakis S Gross C 2003. Surgical technique has been influenced by an As endoscopic sinus surgery has progressed. improved understanding of wound healing and over the last decade new techniques have been in. mucosal physiology The concept of mucosal pres troduced to aid with the resection of tumors in re. ervation has become central to modern endoscopic gions that traditionally have been difficult to ac. surgical technique Histologic studies support the cess or have required significant resection of nor. principle that minimizing the trauma to and the de mal tissue to access the tumors London S et al. nuding of sinus mucosa accelerates postoperative 2002 Anand V Schwartz T 2007 In general the. wound healing and optimizes recovery of sinus approaches are more suitable for benign tumors. mucosal function Wormald P 2005 New instru inverted papilloma juvenile angiofibroma but. mentation has facilitated the consistent execution as techniques and adjuvant therapy develop these. of mucosal preserving technique A variety of techniques will become useful for the resection of. through cutting forceps allows the precise removal some malignant tumors adenocarcinoma olfac. of diseased mucosa without stripping adjacent tis tory neuroblastoma carcinosarcoma squamous. sue Microdebriders also provide a means of effi cell carcinoma melanoma chondrosarcoma. cient sharp tissue dissection that minimizes muco Endoscopic techniques have also been success. sal stripping Bernstein J et al 1998 Microde fully applied to a wide variety of skull base le. briders have also transformed the technique of sions In the endoscopic era the newly acquired. nasal polypectomy offering better visualization facility for approaching the skull base transnasally. and reduced blood loss than possible with standard has created a new standard for minimally invasive. resection techniques Furthermore tissue resected approaches to cerebrospinal fluid leaks and en. through microdebriders retains adequate histologic cephaloceles especially those involving the eth. integrity to allow pathologic diagnosis of resected moid or medial sphenoid sinuses Surgeons can. specimens Zweig J et al 2000 now approach the resection of skull base lesions. One of the more important technologic advances with greater confidence knowing that most collat. that has directly influenced the discipline of rhinol erally induced skull base defects are endoscopi. ogy is computer aided navigation in endoscopic cally reparable In transsphenoidal pituitary sur. surgery Derived from stereotactic technologies in gery use of endoscopic technique has resulted in. brain and spinal surgery image guidance technol shorter hospitalization times and decreased patient. ogy as developed for rhinologic surgery has enabled morbidity Jho H 2001 Nasseri S et al 2001. the intraoperative localization of critical intranasal Angled nasal endoscopy also offers the ability to. and skull base surgical anatomy during endoscopic visualize areas where residual hypophyseal tumor. procedures The two primary modalities of localiza may persist unrecognized Beyond the sella le. tion optical and electromagnetic offer accuracy sions of the clivus petrous apex and orbital apex. within 2 mm under optimal circumstances Anon J have also been successfully approached endoscop. 1998 Metson R et al 1998 ically Kingdom T DelGaudio J 2003. Indication for the use of computer aided local Endoscopic endonasal surgery is a minimally. ization for endoscopic endonasal surgery contin invasive technique used mainly in neurosurgery. ues to evolve The technology has been used to and otolaryngology A neurosurgeon or an otolar. confirm the location of critical structures such as yngologist using an endoscope that is entered. the orbit cranial base optic nerve and carotid ar through the nose fixes or removes brain defects or. tery Localization is particularly useful when criti tumors in the anterior skull base Normally an oto. cal landmarks are missing or altered because of laryngologist performs the initial stage of surgery. previous surgery or erosive or distorting effects of through the nasal cavity and sphenoid bone a neu. disease American Academy of Otolaryngology rosurgeon performs the rest of the surgery involv. Head and Neck Surgery Foundation 2002 ing drilling into any cavities containing a neural. Mesropyan H B et al The New Armenian Medical Journal Vol 11 2017 No 3 p 4 10. organ such as the pituitary gland One criticism, might be that it is impossible to remove a tumor of. any significant size en bloc using this approach, From a practical standpoint it is rarely possible to. remove these tumors en bloc through any open ap,proach currently popular e g a combined subcra. nial and midfacial degloving approach has been, described for large inverted papillomas by D Fliss. and co authors 2000 An experienced endo,scopic sinus surgeon however would have no dif.
ficulty removing these same tumors through a trans. nasal approach with much lower hospital stays and, associated morbidity rates Chee L Sethi D 1999 Figure 1 Transnasal approach to the sella and clivus. Califano J et al 2000 Remove the intersphenoidal septae Spt and iden. In addition to the obvious cosmetic advantage tify the sella S planum sphenoidale PS superi. orly and the clivus C inferiorly The carotid protu. of an endonasal approach there are also practical,berances CP overlie the vertical segment of the. advantages The midface degloving approach and carotid artery opticocarotid recess OC on each. the lateral rhinotomy medial maxillectomy ap side of the clivus. proach for inverted papilloma have the potential,for cosmetic deformity and an adverse functional. impact on nasal airflow An endonasal approach,avoids both problems Lueg E et al 1998. Surgical approaches to the anterior skull base,The transnasal approach Fig 1 2 is used when.
the surgeon needs to access the roof of the nasal,cavity the clivus This approach is used to remove. chordomas chondrosarcoma inflammatory le,sions of the clivus or metastasis in the cervical. spine region The anterior septum or posterior sep,tum is removed so that the surgeon can use both. sides of the nose One side can be used for a micro Figure 2 The intraoperative endonasal view of planum. sphenoidale and sella,scope and the other side for surgical instruments. or both sides can be used for surgical instruments is then removed to allow the surgeon a panoramic. Ciric I et al 1997 Anand V Schwartz T 2007 view of the area Kabil M et al 2005 Kaylie D et. This approach is the most common and useful al 2006 Anand V Schwartz T 2007. technique of endoscopic endonasal surgery and was The invention of the angled endoscope is used to. first described in 1910 concurrently by Harvey go beyond the sella to the suprasellar region This is. Cushing and Oskar Hirsch Liu J et al 2005 Lan done with the addition of four approaches First the. zino G et al 2002 This procedure allows the sur transtubercular and transplanum approaches are. geon to access the sellar space or sella turcica The used to reach the suprasellar cistern The lateral ap. sella is a cradle where the pituitary gland sits proach is then used to reach the medial cavernous. Under normal circumstances a surgeon would use sinus and petrous apex Lastly the inferior approach. this approach on a patient with a pituitary adenoma is used to reach the superior clivus It is important. The surgeon starts with the transnasal approach that the Perneczky triangle is treated carefully This. prior to using the transsphenoidal approach This al triangle has optic nerves cerebral arteries the third. lows access to the sphenoid ostium and sphenoid cranial nerve and the pituitary stalk Damage to any. sinus The sphenoid ostium is located on the antero of these could provide a devastating post surgical. superior surface of the sphenoid sinus The anterior outcome Alfieri A Jho H 2001 Anand V Schwartz. wall of the sphenoid sinus and the sphenoid rostrum T 2007 Lanzino G et al 2002. The New Armenian Medical Journal Vol 11 2017 No 3 p 4 10 Mesropyan H B et al. The transpterygoidal approach enters through must be removed Then the surgeon slides the en. the posterior edge of the maxillary sinus ostium and doscope into the nasal choana until the sphenoid. posterior wall of the maxillary sinus This involves ostium is found Then the mucosa around the os. penetrating three separate sinus cavities the eth tium is cauterized for microadenomas and removed. moid sinus the sphenoidal sinus and the maxillary completely for macroadenomas Then the endo. sinus Surgeons use this method to reach the cavern scope enters the ostium and meets the sphenoid. ous sinus lateral sphenoid sinus infratemporal rostrum where the mucosa is retracted from this. fossa pterygoid fossa and the petrous apex Sur structure and is removed from the sphenoid sinus. gery includes a uninectomy removal of the osteo to open the surgical pathway Then the floor of the. meatal complex a medial maxillectomy removal sella turcica is opened with a high speed drill being. of maxilla an ethmoidectomy removal of eth careful to not pierce the dura mater Once the dura. moidectomy removal of ethmoid cells and or eth is visible it is cut with microscissors for precision. moid bone a sphenoidectomy removal of part of If the tumor is small the tumor can be removed by. sphenoid and removal of the maxillary sinus and an en bloc procedure which consists of cutting the. the palatine bone The posterior septum is also re tumor into many sections for removal If the tumor. moved at the beginning to allow use of both nostrils is larger the center of the tumor is removed first. Anand V Schwartz T 2007 Cantu G et al 2010 then the back then the sides then top of the tumor. The transethmoidal approach makes a surgical to make sure that the arachnoid membrane does. corridor from the frontal sinus to the sphenoid sinus not expand into the surgical view This will happen. This is done by the complete removal of the eth if the top part of the tumor is taken out too early. moid bone which allows a surgeon to expose the After tumor removal cerebrospinal fluid leaks are. roof of the ethmoid and the medial orbital wall tested for with fluorescent dye and if there are no. This procedure is often successful in the removal of leaks the patient is closed Anand V Schwartz T. small encephaloceles of the ethmoid osteomas of 2007 Zhang Y et al 2008 Hobbs C et al 2011. the ethmoid sinus wall or small olfactory groove Approach to suprasellar region This tech. meningiomas However with larger tumors or le nique is the same as to the sellar region However. sions one of the other approaches listed above is the tuberculum sellae is drilled into instead of the. required Anand V Schwartz T 2007 sella Then an opening is made that extends half. a Approach to sellar region Fig 3 For removal way down the sella to expose the dura and the in. of a small tumor it is accessed through one nostril tercavernous sinuses are exposed When the optic. However for larger tumors access through both chiasm optic nerve and pituitary gland are visible. nostrils is required and the posterior nasal septum the pituitary gland and optic chiasm are pushed. Figure 3 The intraoperative endoscopic view a Endonasal transsphenoidal approach to the planum. sphenoidale and tuberculum sellae and identification of the meningioma b The tumor was removed. completely under endoscopic vision, Mesropyan H B et al The New Armenian Medical Journal Vol 11 2017 No 3 p 4 10.
apart to see the pituitary stalk An ethmoidectomy may produce less sinonasal complications Griffith. is performed the dura is then cut and the tumor is H Veerapen R 1987 Stevens M Apfelbaum R. removed These types of tumors are separated into 1990 Cooke R Jones R 1994. two types Badie B et al 2000 Jane J et al 2002 Endoscopic transsphenoidal approaches by way. Anand V Schwartz T 2007 of transnasal or transseptal routes have been the. Prechiasmal lesions This tumor is closed to the subject of multiple reports Endoscopes with angled. dura The tumor is decompressed by the surgeon lenses provide direct visualization of the surgical. After decompression the tumor is removed taking field Several reports demonstrate that endoscopes. care to not disrupt any optic nerve or major arteries provide superior exposure when compared with mi. Postchiasmal lesions This time the pituitary stalk croscopes Sheehan M et al 1999 Spencer W et. is in the front because the tumor is pushing it towards al 1999 Some investigators report superior out. the area the dura was opened Removal then starts on comes comparing endoscopic techniques with mi. both sides of the stalk to preserve the connection be croscopic techniques Wurster C Smith D 1994. tween the pituitary and the hypothalamus and above Jarrahy R et al 2000 Hormann K 2000 Kabil M. pituitary gland to protect the stalk The tumor is care et al 2005 Schaberg M et al 2010 In addition. fully removed and the patient is closed up the endoscopic transnasal transsphenoidal approach. Skull base reconstruction When there is a obviates the need to use a nasal speculum with its. development and improvement of the skull base surgery the success of this type of surgery de pends on perfect knowledge of the anatomy intense endoscopic surgery training and a multidis ciplinary partnership keywords tumor endonasal approaches sinus surgery skull base surgery Hayastan B Mesropyan 16a V Papazyan Street 72 app

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