Dr. med. Alberto Consuegra (Zürich / CH), KD Dr. med. Hans-Rudolf Briner (Zürich / CH), Prof. Dr. med. Daniel Simmen (Zürich / CH), Prof. Dr. med. Robert Reisch (Zürich / CH)
Abstract-Text
Introduction: The conventional microsurgical technic has been the gold standard in the transnasal surgery of pituitary adenomas and central skull base tumors for many years. Nonetheless, over the past 2 decades, a slow shift towards purely endoscopic techniques has been observed (Májovský 2022). The endoscopic techniques not only offer a safe approach with better surgical and oncological outcomes (Karppinen 2015, Razak 2013, Castaño-Leon 2020) but with the proper interdisciplinary work the postoperative rhinological quality of life can be minimized or even improved (Graham 2009, Kahilogullari 2013, Eördögh 2017). Moreover, because of the avoidance of the speculum, the use of the endoscope comes with a better range of movement, allowing the surgeon to expand the approach widely in all directions.
Methods and results: In our center, all endoscopic approaches are performed interdisciplinary in a 4-hand technique. The surgical plan is always considered depending on individual tumor location and extension, as well as, the anatomical nasal conditions of each patient. The transnasal endoscopic technique not only allows to reach the sellar and parasellar space but also to control inferiorly through the transclival approach, and superiorly over the transtuberculum/transplanum approach. In addition, with the lateral extension according to the transmaxillary/transpterigoyd/infratemporal approach, we are able to visualize the sinus cavernosus and petrous apex. If necessary, we tailor the approach from mono-nostril to bi-nostril or even combine the transnasal dissection with a transcranial exposure in one session. In this way, a combined transnasal-transcranial can be used in cases where the intracranial expansion of the tumor cannot be reached in a purely transnasal way.
Conclusion: Over the past 14 years, our interdisciplinary rhino-neurosurgical team in Zürich has been developing a minimal-invasive tailored transnasal endoscopic approach. The main idea is to generate enough working space through the nose without compromising the olfactory mucosa and without the removal of nasal turbinates. The concept is to be as minimal-invasive as possible but to be able to expand the approach as much as necessary. The design of a structured, case-specific, surgical plan allows the surgical treatment of all anterior skull-base tumors, going from small midline tumors to large extensive ones (a.e. chordomas, sarcomas, and aesthesioneuroblastomas).