1. 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

2. 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....

3. 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

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

5. 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

6. 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

7. 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

8. Imaging Contrast CT, CT angio

9. Imaging MRI, MR angio

10. Imaging angiography, selective embolisation

11. benign angiomyoma

16. inverted papilloma

17. angiofibroma

18. adenóm hypofýzy pituitary gland adenoma

19. adenocarcinoma

20. esthezioneuroblastoma

21. SNUC -Intracranial spread

22. esthesioneuroblastoma

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

25. 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

26. 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...)

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

28. 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

29. „šukran“ thank you for your attention