Avoiding pitfalls in Endoscopic skull base

surgery

By

Dr. T. Balasubramanian

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 Safe endoscopic skull base surgery How?

Introduction:

The advantages of endoscopic approach to skull base are many. They include:

1. It is the most direct route to anterior skull base. This approach provides access
to the following areas Sella, Cribriform plate, Planum sphenoidale, suprasellar
cistern, Clivus, Pterygopalatine fossa and adjacent parasellar areas.
2. In this approach there is decreased retraction of brain and cranial nerves when
compared to that of conventional neurosurgical apporaches.
3. Endoscope offers excellent visualization of the tumor and the surrounding
neurovascular structures
4. Post operative recovery time is short when compared to that of conventional
neurosurgical approaches

As with any other procedure this method also has its flip side, which includes a steep
learning curve, and need to collaborate with neurosurgeon. A cohesive collaboration
with neurosurgeon is a must for successful endoscopic skull base surgical
procedures.The complicated anatomy of skull base has managed to bridge these two
specialities. In a nut shell an otolaryngologist navigates the pathway to the
intracranial lesion while the neurosurgeon removes the tumor.

Dangers of endoscopic skull base surgery:

Since the skull base has many vital structures it should be performed with the highest
degree of deligence and skill. The potential complications of any endoscopic skull
base surgery include:

1. CSF rhinorrhoea
2. Injury to great vessels (internal carotid artery and its branches inside the skull)
3. Injury to optic nerve
4. Injury to other cranial nerves
5. Bleeding from cavernous sinus
6. Meningitis

Steps taken to prevent these complications include:

CT MRI scan review:

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Meticulous pre operative review of CT and MRI scans of the patient. A CT scan
picture not only provides critical information about anatomical landmarks it also
shows up the anatomical variations. While studying the CT scan images lamina
papyracea should be looked for evidence of dehiscence.

Coronal CT image showing lamina papyracea

The degree of pneumatization of sphenoid sinus should be evaluated. This will

reveal to the surgeon the exact amount of bone that must be drilled to reach the
pathology.

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 CT image showing sphenoid pneumatization. * indicate the thickness of bone that
must be drilled to reach the lesion

The presence of onodi cells should be noted. This cell is a well pneumatized
posterior ethmoidal cell extending up to the anterior wall of sphenoid sinus enclosing
the optic nerve / carotid artery. Eventhough presence of onodi cell is not a
contraindication for endoscopic skull base surgery it must be appreciated prior to
surgery to avoid injury to this critical neurovascular bundle.

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 Axial CT image showing the onodi cell

Intersphenoidal septae:

CT images should be utilized to look for the intersphenoidal septae. Usually there
will be one bony septum separating the right from the left sphenoid sinuses. It may
also be multiple / asymmetric also. The exact site of insertion of this septum in the
posterior wall of sphenoid sinus serves as a valuable landmark in identifying internal
carotid artery during surgery. If the image shows the carotid artery to be lateral to the
insertion of septum then the surgeon can be sure of not damaging the artery if he
stays medial to the septum. If the carotid artery lies medial to the septum then the
surgeon will be forewarned about this anatomy. Rarely the septum may be attached
to the carotid canal itself. In these cases the operating surgeon should not avulse the
septum but should use true cut instruments to nibble it out. This will protect the
carotid artery from inadvertant surgical trauma.

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 CT image showing the intersphnoidal septum

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 CT scan image showing asymmetric inter sphenoidal septum (arrow)

Picture showing endoscopic view of inter sphenoidal septum

Strict adherence to mucosal sparing technique:

While performing endoscopic skull base surgery it is important to maximally
preserve the nasal mucosa by resorting to minimal access technique. It is also
prudent to retain the middle turbinate during the surgical procedure. Simple gentle
lateralization of it is sufficient to improve access to the surgical area. This mucosal
preservation technique allows the nasal mucociliary mechanism to recover at the
earliest with minimal crust formation. The presence of an intact nasal mucociliary
mechanism will help in preventing infections. Excessive denudation of nasal mucosa
will eventually lead to crust formation, atrophic changes, and synechiae formation. If
need arises a nasoseptal flap can be harvested to close troublesome CSF leaks, in
these patients the sphenoid sinus should be exposed and denuded off its mucosa in

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order to prevent mucocele formation.

Use of intraoperative doppler ultrasound to localize carotid artery:

This is very useful in removing the bony covering over the internal carotid artery and
when the anterior wall of cavernous sinus is exposed. Doppler is superior to image
guidance because of its ability to measure blood flow in real time. This will really
ensure that the surgeon is not lost within the sphenoid sinus.

Identification of intraoperative CSF leak using intrathecal fluorescein dye:

CSF leaks are common complication of endoscopic skull base surgery and must be
repaired at the earliest to prevent intracranial infections. Identification of CSF leaks
on the table while performing surgery is virtually impossible. The so called “wash
out sign” is highly unreliable. Intrathecal administration of fluorescein dye will help
in identifying CSF leaks on the table. 0.25 ml of 10% fluorescein mixed in 10 ml of
CSF is injected intrathecally before surgery. Leaks if any identified on the table
should be closed primarily under endoscopic guidance. Studies reveal a success rate
of more than 90% when these leaks are closed primarily, with the added advantage of
avoiding second look surgical procedure. Ideal aim of any CSF leak repair is to
create water tight separation between sinonasal cavity and intracranial contents.
Multilayered closure of skull base defects really helps in creating this watertight
compartment between sinonasal cavity and intracranial contents. Multilayered
closure include:

1. Fascia lata layer

2. Rigid bone like vomer (supporting material)
3. Naso septal flap
4. Layer of tissue sealant

Obliterating dead space created by removal of tumor:

This is another vital step necessary to avoid potential complications. Dead space
after tumor removal should be filled with abdominal fat.

Use of lumbar drain post operatively to reduce CSF pressure:

Placement of lumbar drain post operatively helps to reduce CSF pressure thereby
minimizing CSF leak. Placement of lumbar drain in indicated under the following
scenario:

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 1. Pathology of the tumor
2. Size of the tumor
3. Size of the skull defect
4. Presence of post op hydrocephalus
5. Increase of CSF pressure post operatively

Lumbar drain is an absolute indication if the tumor is suspected to be malignant in

nature. If the tumor happens to be meningioma / craniopharyngeoma then a wide
opening need to be created at the arachnoid cistern for their complete removal. This
leads to an increase in the risk of CSF leak.

Periodic post operative cleansing of nasal cavity by removal of crusts, clot and other
debris will help in minimizing the risk of complications.

Early intraopeative identification of critical neuro vascular structures will help in

minimizing complications. If possible the blood supply to the tumor should be
controlled before starting the debulking procedure. Tumors should first be debulked
before trying to dissect its periphery. This procedure is followed meticulously will
help in complete tumor removal without damaging the adjacent vital structures.

Role of neuroanesthesia in preventing complications:

In neuroanesthesia instead of hypotensive anesthesia the patient is maintained in a

slightly hypertensive level in order to maintain cerebral perfusion rate. Intra arterial
blood pressure monitoring (in real time) and central venous catheterization for
administration of fluids and drugs is a must. Intraoperative monitoring of
somatosensory potentials is a must. This will ensure adequate monitoring of the
muscle tissues supplied by cranial nerves.

Real time Intraoperative image guidance systems:

This is another vital equipment which is used to minimize complications during

endoscopic skull base surgery. Since the intranasal anatomy is highly variable it is
imperative on the part of the surgeon to closely monitor the exact location of surgery.
This is made possible by real time image guidance systems. It is possible to identify
and preserve critical structures and anticipate the position of blood vessels during
surgery.

Use of specialized surgical instruments:

This is another vital area. Many of the endonasal instruments were designed for
endoscopic sinus surgery and were found to be too short to reach the skull base or

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their angles insufficient for skull base access. Currently lot of modified equipments
are available that have the excellent reach and capabilities of neurosurgical
instruments. Instruments like bipolar cautery, high speed drills and ultrasonic
aspirators have become longer to accomodate the nasal corridor approach.

Figure showing some of the instruments used in skull base surgery

Hemostasis:

Ensuring adequate hemostasis a must for any successful endoscopic skull base
surgery. Bleeding will virtually make endoscopic vision useless. Adequate
hemostasis can be acheived by using bipolar cautery, sharp dissection of tissues,
avoiding blunt dissection and unnecessary traction. It should be borne in mind
bleeding from tumors and its vasculature is unavoidable.
Low flow bleeding from mucosa, bone or veins can be controlled by warm saline
irrigation. Warm water irrigation reduces low flow bleeding by:

1. Enhanced platelet activation

2. Reduction of interstitial oedema
3. Enhanced enzymatic activity which increases coagulation
Ideal temperature of saline used for irrigation is 40 degrees centigrade. Anything
more than this will cause cerebral hyperthermia.

Brisk bleeding from dural venous sinuses should be arrested by using topical
hemostatic agents like flowseal.

High flow arterial bleeds should always be cauterized. Liga clips can be applied to
secure the bleeder. Two surgeon approach will help in improved visualization in

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cases of high flow arterial bleeds. One surgeon uses suction through the opposite
nose to suck out blood while another surgeon operates through the other nasal cavity
using endoscope to visualize the area.

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