Endoscopic Endonasal Transsphenoidal Resection Of Pituitary Adenomas: Preliminary Evaluation Of Consecutive Cases.

Endoscopic endonasal transsphenoidal surgery has gained increasing acceptance by otolaryngologists and neurosurgeons. In many centers throughout the world, this technique is now routinely used for the same indications as conventional microsurgical technique for pituitary tumors. To present a surgical experience of consecutive endoscopic endonasal trans-sphenoidal resections of pituitary adenomas. In this study, consecutive patients with pituitary adenomas submitted to endoscopic endonasal pituitary surgery were evaluated regarding the rate of residual tumor, functional remission, symptoms relief, complications, and tumor size. Forty-seven consecutive patients were evaluated; 17 had functioning adenomas, seven had GH producing tumors, five had Cushing's disease, and five had prolactinomas. Of the functioning adenomas, 12 were macroadenomas and five were microadenomas; 30 cases were non-functioning macroadenomas. Of the patients with functioning adenomas, 87% improved. 85% of the patients with visual deficits related to optic nerve compression progressed over time. Most of the patients with complaints of headaches improved (76%). Surgical complications occurred in 10% of patients, which included with two carotid lesions, two cerebrospinal fluid leaks, and one death of a patient with a previous history of complications. Endoscopic endonasal pituitary surgery is a feasible technique, yielding good surgical and functional outcomes, and low morbidity.

Morphometric evaluation of the sphenopalatine foramen for endonasal surgery

Objective: Ligation of the sphenopalatine artery is used to treat severe nasal haemorrhage. The objective of the study was to investigate the numerical variation of the sphenopalatine foramen (SPF), its relation to the ethmoid bone crista of the palatine bone in the lateral nasal wall, its distance from the anterior nasal spine and the angle between this distance and the anterior nasal floor. Material and Methods: Fifty-four hemiskulls were submitted to anatomical study and measurements using the Image Tool 3.0 software. Results: The SPF was single in 87% of the specimens, and more than one orifice was present in 13%. It was possible to establish a relation with the ethmoid crista, which is a surgical reference for the SIT location. The mean values of the measurements were significantly higher in the hemifaces than in the hemiskulls ranging from 54 to 63mm, and angulation ranged from 20 to 32 degrees. Conclusions: In most specimens studied, the SPF was single and located in the superior nasal meatus. The distances measured suggest that these values can be used as distance references for the use of the endoscope for ligation or endonasal cauterization of the branches of the sphenopalatine artery, preventing possible errors and complications.

Complicações rinossinusais após descompressão orbital em técnica externa e endonasal combinada

Muitas técnicas de descompressão orbital têm sido utilizadas no tratamento da oftalmopatia por Graves. Recentemente, introduziu-se a cirurgia endoscópica endonasal na descompressão de órbita, como técnica isolada ou combinada com as já existentes, acreditando proporcionar melhor visão da parede medial da órbita e menor incidência de infecção bacteriana quando a parede medial é acessada por endoscópio. OBJETIVO: Avaliar as complicações após a descompressão orbital por técnica combinada assistida por endoscopia na prevenção de infecção rinossinusal. FORMA DE ESTUDO: Clínico Prospectivo. MATERIAL E MÉTODO: 16 pacientes 18 órbitas foram submetidos à descompressão orbital no Setor de Órbita do Departamento de Oftalmologia da Escola Paulista de Medicina UNIFESP. RESULTADOS: Quatro pacientes, durante o acompanhamento por tomografia no pós-operatório, apresentaram velamento do seio maxilar ou frontal, sem sintomatologia. CONCLUSÃO: A descompressão orbital por via externa combinada com a via endonasal auxiliada por endoscopia mostrou-se eficaz na prevenção de sinusite clinicamente manifesta e suas complicações, embora no acompanhamento tomográfico 22% dos pacientes apresentaram velamento do seio maxilar ou frontal.

Dacriocistorrinostomia endonasal em crianças

OBJETIVO: Nosso objetivo foi verificar se os resultados com a dacriocistorrinostomia endonasal endoscópica em crianças com obstrução do canal nasolacrimal permitem considerá-la uma alternativa de tratamento aceitável para crianças. FORMA DE ESTUDO: clínico com coorte transversal. MATERIAL E MÉTODO: Vinte e sete dacriocistorrinostomias endonasais endoscópicas foram realizadas em crianças de 2 a 12 anos com obstrução do canal nasolacrimal. Todas as crianças haviam sido tratadas por sondagem lacrimal, sem resultado. A técnica utilizou uncinectomia e uma abertura do saco lacrimal pequena. O seguimento foi de 3 meses. RESULTADOS: Bom resultado foi verificado após 21 cirurgias (77,8% de sucesso). A única complicação verificada foi prolapso da intubação com silicone em 1 caso. CONCLUSÃO: Nossos resultados permitem confirmar a dacriocistorrinostomia endonasal endoscópica como alternativa válida e segura para o tratamento de crianças com obstrução nasolacrimal resistente a sondagens.

Analysis of functional and anatomical success following endonasal dacryocystorhinostomy

RésuméLes sténoses des voies lacrymales sont fréquentes surtout chez les patients âgés et provoquent en général un epiphora avec parfois des dacryocystites aiguës ou chroniques. La dacryocystorhinostomie par voie externe (DCREX) a été la technique de choix pour traiter les sténoses post-canaliculaires au XXe siècle. Avec l'avènement de l'endoscopie nasale, l'abord endonasal est devenu facilement accessible et depuis une dizaine d'années, la dacryocystorhinostomie par voie endonasale (DCREN) est en train de supplanter la DCREX dans la majorité des cas.Le but de ce travail est de déterminer les étiologies des sténoses des voies lacrimales, d'évaluer le taux de succès et les complications de la DCREN et de détailler les gestes associés peropératoires.Cette étude rétrospective porte sur 98 patients ayant subi 104 DCREN entre janvier 1994 et février 2006. 78 patients (53 femmes et 25 hommes) présentant 84 sténoses post- canaliculaires remplissent les critères d'inclusion de l'étude. L'âge moyen est de 59 ans (4 - 89 ans).Les résultats obtenus montrent un taux de succès fonctionnel de 94.9% après une première intervention (59/84 DCREN) et de 63.6% pour les DCREN secondaires qui nous ont été référées après d'autres interventions des voies lacrymales (25/84 DCREN). Le suivi postopératoire est de 36,8 mois (12-77 mois). On dénombre 61 gestes rhino-sinusaux associés à la DCREN. Les complications per- et postopératoires sont rares, essentiellement liées aux drains bicanaliculaires. Une étiologie n'a été retrouvée que dans 28% des cas.En conclusion, la DCREN donne d'excellents résultats et peu de complications. En raison des nombreux avantages par rapport à la voie externe et la possibilité du traitement simultané de la pathologie ORL parfois associée, la DCREN est devenue le traitement de premier choix pour les sténoses postcanaliculaires. Le principal défi, quelque soit le type de DCR, est de poser la bonne indication opératoire et en cas d'échec opératoire savoir méticuleusement analyser ses causes

Analysis of Functional and Anatomic Success Following Endonasal Dacryocystorhinostomy

Objectives: The aim of this study was to assess the concomitant perioperative procedures, the causes of nasolacrimal duct obstruction, the success rate, and the complications associated with endonasal dacryocystorhinostomy (ENDCR).Methods: In this single-center retrospective study, 98 patients underwent 104 ENDCRs between January 1994 and February 2006. There were 78 patients with 84 nasolacrimal duct obstructions who were included in this study.Results: The overall functional success rate with improvement in symptoms was 94.9% for primary surgery (59 of 84 obstructions) and 63.6% for salvage surgery after failure of primary surgery performed in another hospital (25 of 84 obstructions). The mean follow-up time was 36.8 +/- 17.11 months. Primary surgery showed better results, with a complete success rate of 93.2%, than did salvage surgery, with a success rate of only 68%. Persistent symptoms, despite an open rhinostomy, were found in 1.7% of patients with primary surgery and in 12% of those with salvage surgery. Failure of ENDCR was observed in 3.4% of patients after primary surgery and in 20% after salvage surgery. We encountered only minimal perioperative complications, and these were essentially related to lacrimal intubation.Conclusions: Because of the possibility of treating concomitant sinonasal disorders, the cosmetic advantages, and the excellent results, ENDCR represents the procedure of choice for treating nasolacrimal duct obstructions. The main challenge lies in the exact preoperative assessment, as well as postoperative evaluation in case of failure.

Occam's razor in minimally invasive pituitary surgery: tailoring the endoscopic endonasal uninostril trans-sphenoidal approach to sella turcica.

BACKGROUND: Since the introduction of the endoscopic endonasal approaches in the field of skull base surgery during the last two decades, several variants of the sella turcica endoscopic surgery have been described. The aim of this study is to provide a stepwise description of one of these variants in a minimally invasive/maximally efficient perspective. METHOD: For the majority of our sella turcica pathologies, we have progressively adopted a uninostril endoscopic approach that is very conservative towards the nasal mucosa with a very limited mucosal incision, resection of the vomer and allowing an almost ad integrum sellar floor reconstruction, without compromising the efficacy and completeness of both surgical oncologic and endocrine targets. CONCLUSION: The uninostril trans-sphenoidal endoscopic endonasal approach to sella turcica is tailored to ally maximal efficiency and minimal invasiveness.

Chirurgie endoscopique endonasale des tumeurs de la base du crane : historique, état de l'art et perspectives d'avenir [Shifting paradigm in skull base surgery: Roots, current state of the art and future trends of endonasal endoscopic approaches].

During the last two decades, endoscopic endonasal approach has completed the minimally invasive skull base surgery armamentarium. Endoscopic endonasal skull base surgery (EESBS) was initially developed in the field of pituitary adenomas, and gained an increasing place for the treatment of a wide variety of skull base pathologies, extending on the midline from crista galli process to the occipitocervical junction and laterally to the parasellar areas and petroclival apex. Until now, most studies are retrospective and lack sufficient methodological quality to confirm whether the endoscopic endonasal pituitary surgery has better results than the microsurgical trans-sphenoidal classical approach. The impressions of the expert teams show a trend toward better results for some pituitary adenomas with the endoscopic endonasal route, in terms of gross total resection rate and probably more comfortable postoperative course for the patient. Excepting intra- and suprasellar pituitary adenomas, EESBS seems useful for selected lesions extending onto the cavernous sinus and Meckel's cave but also for clival pathologies. Nevertheless, this infatuation toward endoscopic endonasal approaches has to be balanced with the critical issue of cerebrospinal fluid leaks, which constitutes actually the main limit of this approach. Through their experience and a review of the literature, the authors aim to present the state of the art of this approach as well as its limits.

Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study

Introduction. The purpose of the present contribution is to perform a detailed anatomic and virtual reality three-dimensional stereoscopic study in order to test the effectiveness of the extended endoscopic endonasal approaches for selected anterior and posterior circulation aneurysms. Methods. The study was divided in two main steps: (1) simulation step, using a dedicated Virtual Reality System (Dextroscope, Volume Interactions); (2) dissection step, in which the feasibility to reach specific vascular territory via the nose was verified in the anatomical laboratory. Results. Good visualization and proximal and distal vascular control of the main midline anterior and posterior circulation territory were achieved during the simulation step as well as in the dissection step (anterior communicating complex, internal carotid, ophthalmic, superior hypophyseal, posterior cerebral and posterior communicating, basilar, superior cerebellar, anterior inferior cerebellar, vertebral, and posterior inferior cerebellar arteries). Conclusion. The present contribution is intended as strictly anatomic study in which we highlighted some specific anterior and posterior circulation aneurysms that can be reached via the nose. For clinical applications of these approaches, some relevant complications, mainly related to the endonasal route, such as proximal and distal vascular control, major arterial bleeding, postoperative cerebrospinal fluid leak, and olfactory disturbances must be considered

Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients

The authors investigate the complications of transnasal transsphenoidal endoscopic surgery in the treatment of 301 patients with pituitary adenomas. A retrospective analysis of complications in 301 patients submitted to transsphenoidal transnasal endoscopic surgery at the General Hospital of Fortaleza, Brazil between January 1998 and December 2009. The complications were divided in two groups: anatomical (oronasofacial, sphenoid sinus, intrasellar, suprasellar and parasellar) and endocrinological complications (anterior and posterior pituitary dysfunctions). We observed a total of 81 complications (26.9%) in our series. Anatomical complications occurred in 8.97% (27 cases): 8 CSF postoperative leaks (2.6%), 6 cases (1.9%) of delayed nasal bleeding, 5 cases (1.6%) of sphenoidal sinusitis, 3 cases (0.9%) of carotid artery lesion, 2 cases of meningitis (0.6%) and one case (0.3%) of each of the uncommon following complications: intrasella-suprasella hematoma, pontine hematoma and chiasmaplexy. Endocrinological complications occurred in 17.9% (54 cases): additional postoperative anterior lobe insufficiency in 35 cases (11.6%), and postoperative diabetes insipidus in 19 cases (6.3%). In our series, 3 cases of deaths (not directly related to the procedure) were also observed. Endoscopic transsphenoidal surgery represents an effective option for the treatment of patients with pituitary tumor. Complications still occur and must be reduced as much as possible. Successful endoscopic pituitary surgery requires extensive training in the use of an endoscope and careful planning of the surgery. Additional improvement can be expected with greater experience and new technical developments.

Endonasal endoscopic exposure of the internal carotid artery: An anatomical study

Objectives/Hypothesis: The aim of this work was to define the anatomical landmarks, limitations, and difficulties of obtaining internal carotid artery (ICA) exposure via endonasal endoscopic approaches (EEA).

Analysis of functional and anatomic success following endonasal dacryocystorhinostomy

The aim of this study was to assess the concomitant perioperative procedures, the causes of nasolacrimal duct obstruction, the success rate, and the complications associated with endonasal dacryocystorhinostomy (ENDCR).

Insertion of double bicanalicular silicone tubes after endonasal dacryocystorhinostomy in lacrimal canalicular stenosis: a 10-year experience

To assess the long-term results of double bicanalicular silicone tubes in canalicular (presaccal) stenosis of the nasolacrimal duct system, a retrospective follow-up was performed on patients operated between 1992 and 2002. Forty-five patients were included in the study, 44 of whom had eyes with canalicular stenosis (primary dacryocystorhinostomy), 4 with congenital agenesis of the lacrimal duct system, and 3 cases after primary external dacryocystorhinostomy. Double bicanalicular silicone tubes were inserted, fixed in the vestibulum nasi, and left in place as long-term space holders. Of the 51 endonasal primary dacryocystorhinostomies with canalicular stenosis, 32 (63%) became symptom-free after one procedure. Nineteen (37%) patients had a relapse. Double silicone bicanalicular tube insertion as long-term spacers in canalicular stenoses has a number of advantages, but canalicular stenoses still remain a challenging area.

Tratamento endoscópico endonasal de tumores nasossinusais malignos : resseção e reconstrução

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014