Even though the endoscopic approach to the skull base may have advantages, physicians need to use the surgical approach that is most appropriate for the patient’s disease, said Dr. Snyderman. “Going through the nose is sometimes a better approach than going through the side of head and through the cranium,” he said. “It should be individualized for the patient.”
Explore this issue:November 2007
Contraindications, Precautions, and Limitations
Although endoscopic skull base surgery is advantageous for a variety of indications, the procedure also has a number of contraindications and should be approached with several precautions in mind, agreed the physicians interviewed for this article. The surgery also has some limitations and a few disadvantages when compared with open procedures.
Extremely vascular tumors are a relative contraindication, and whether or not to perform the procedure depends on the technical expertise of the physician, said Dr. Batra.
The procedure is also contraindicated for extensive tumors that involve the facial soft tissues, Dr. Batra said. A combined open and endoscopic approach may be possible, but this sort of tumor is most often amenable to an open procedure, he explained.
If the tumor is a massive bilateral growth, removing it with endoscopic skull base surgery also depends on the surgeon’s technical expertise, said Dr. Batra.
Additionally, if a skull base tumor involves orbital contents, endoscopic techniques alone are inadequate in most instances, since orbital exenteration will be required, said Dr. Citardi. However, using a combination of open incision and visualization with an endoscope may be possible, he said.
Overall, if the tumor is inoperable by traditional methods, it is not a candidate for curative resection by endoscopic skull base surgery, said Dr. Batra.
Surgeons performing endoscopic skull base surgery should be concerned about approaching critical areas such as the orbit and optic nerve, brain and surrounding dura, and the internal carotid artery, said Dr. Batra.
Endoscopic surgeons also need to be aware of complications such as bleeding, which can be life-threatening, as well as the potential for blindness, brain injury, and spinal fluid leakage, said Dr. Citardi. “That’s why preoperative assessment is very important,” he said. “Patients need to undergo specific imaging and pretreatment planning with a multidisciplinary team.”
To help plan surgery and avoid sensitive structures, physicians view computed tomography (CT) and magnetic resonance images of bony and soft tissue before surgery to map out the sinuses from the eyes to the skull base in three dimensions, said Dr. Batra. “This navigation also helps physicians determine if they are near any critical blood vessels or other structures,” he said.