Development of endonasal surgery in tumours of the PNS and skullbase, why we use it more and more? M.Sičák Klinika otorinolaryngológie a chirurgie hlavy a krku ÚVN Ružomberok a LF SZÚ Bratislava Rinologické dni, Orechová Potôň

Endoscopic endonasal surgery (ESS) Late 80´s- beginning of endoscopic sinus surgery in Europe (Messerklinger, Wigand,Stammberger..) Based on philosophy of functional minimaly invasive surgery of paranasals Criticism about indications, risks, results Limited indications Advanced endoscopic surgery....

Endoscopic endonasal surgery (ESS) Rising numbers : Experiences Safety New indications Concentrations to centers Better results New technologies: Advanced surgery behind borders Endoscopic duraplasty Orbital surgery Pituitary surgery Anterior skull base surgery Anterior cranial fossa Infratemporal fossa Clivus Posterior fossa

CT/MRI navigation, full HD cameras, shavers, drills, light source, endoscopes safety orientation visibility time saving

endoscopic/microscopic endonasal tumor surgery optimal conditions: early diagnosis allows early surgery careful assesment of indication experienced hands (endoscopic centers) training center technology support preoperative embolisation possibility precise imaging- surgical planning

When endoscopic approach ? almost any tumour limited to nasal cavity and PNS some expansive tumours growing behind this anatomic landmarks small invasive tumours infiltrating borders of these landmarks

What else endoscopic approach offers ? visibility : telescope+light+camera versus naked eye centripetal resection- identification of tumor origin- minimalisation of resection good endoscopic access of posterior part of nasal cavity and sinuses –contrary to external approach – where as deep as less visible surgical field pacient – no estetic mutilation

Imaging Contrast CT, CT angio

Imaging MRI, MR angio

Imaging angiography, selective embolisation

benign angiomyoma

inverted papilloma

angiofibroma

adenóm hypofýzy pituitary gland adenoma

adenocarcinoma

esthezioneuroblastoma

SNUC -Intracranial spread

esthesioneuroblastoma

anatomic limits lateral wall of sphenoid sinus Carotid artery Optic nerve Cavernous sinus floor of nasal cavity intraconal orbital space

Technical limits due to difficult access anterior wall of maxilary sinus and zygomatic recess lateral part of inferior orbital wall frontal sinus-anterior, lateral deep intracranial space

What helps? experience with an external approach for tumour removal experiences with complications solution: bleeding controll retrobulbar haemathoma optic nerve surgery experiences with endoscopic duroplasty hight quality technology backround (camera, telescopes, self cleaning system, shaver as a minimum) staff familiar with CT/MRI guided navigation invasive radiologist (preop embolisation, carotid stenting...)

Complications solutions bleeding : hypotensy, prepared patient (embolisation, novoSeven), bipolar targetted coagulation, shaver retrobulbary haemathoma – allways endoscopic decompression (quicker, effective, definitive) CSF leak – endoscopic duroplasty

endoscopic tumor surgery widely accepted surgical modality more precise visualisation tumour origin identification still objective limits : optic nerve, chiasma intraconal orbital structures carotid artery cavernous sinus large intracranial portion

„šukran“ thank you for your attention