The surgery can be done as sort of an en bloc procedure, but I have to tell you we have changed that technique to one that goes in layers. We remove the tumor, the mucosa, the bone, and then the dura. We think that is a safer way of removing the tumor, and it really doesn’t make any difference for the oncology margins as long as it is completely removed. We are going to treat the tumor in the same way we would with the traditional approach.
Explore This IssueNovember 2008
In the operation he described, Dr. Carrau noted that the tumor invaded a larger area than expected, requiring the removal of the olfactory nerves and the dura. This is because when we opened the dura, a portion of the tumor that was not visible from the nasal side had invaded the other side of the dura. If we had stopped our procedure at the dura, we would have left tumor with perineural invasion.
The tumor has to be followed and olfactory tract removed until we obtain negative margins. We are going to have the same defect as if we used the traditional approach.
Dr. Carrau said the advantage of the endoscopic approach, aside from the obvious of not having any facial incisions or scalp incisions and avoiding craniotomy, is that you have much less brain manipulation. This is almost a ‘no touch’ technique regarding the brain that allows us to include patients that before were not surgical candidates.
That is not to say that we tackle all our tumors with an endoscopic approach. You have to understand that at least 50 percent of sinonasal track tumors at our institution are managed with open approaches. If you have tumors that invade the skin, the soft tissues of the orbit, or the frontal sinus, it doesn’t make sense to do it completely with an endoscopic approach, although endoscopic techniques can really be complementary.
Although we have two camps-the traditional camp of ‘we can do it larger’ and the endoscopic camp of ‘we can do it smaller’-we really have to be able to move from one camp to the other, according to the needs of the patient, he said.
Dr. Carrau said that the development of the nasoseptal flap has become a major innovation in endoscopic reconstruction. We preserve the upper portion of the mucosa and we can move the margin of this flap according to the oncologic needs by extending the flap into the floor of the nose and then having a margin at the top. The flap has to be raised early in the surgery and can cause a problem during the surgery, but we just store it in the nasopharynx until it is time to use it. The flap is big and supple. It can reach the anterior of the skull base and the lateral skull base.