Chapter 1 Evolution of Skull Base Surgery: The Multidisciplinary Team Approach

The idea to access the brain through the nose is ancient. There is evidence that during mummification procedures, Egyptian surgeons removed brain tissue transnasally.1,2 In the fifth century BC, the Corpus Hippocraticum described for the first time the anatomy of the paranasal sinuses and their surgery.3 However, the study of the nose and sinus anatomy did not improve until the Renaissance period when Leonardo Da Vinci started to describe the paranasal sinuses from cadaver dissections.4

The maxillary was the sinus first operated; in 1675, Molinetti describes for the first time an opening approach to the maxillary sinus through the cheek.5 In 1893 and 1897, Caldwell and Luc proposed, respectively, a radical surgery of the maxillary sinus by opening its anterior wall, which has been the gold standard of maxillary sinus surgery for many decades.6,7

The transnasal approach of ethmoid sinus was first described by Riberi in 1838 and consolidated by others between 1893 and 1907.4 In 1901, Hirschman visualized for the first time the maxillary sinus through an oroantral fistula using a cystoscope with an electric bulb. In 1902, Reichert performed a maxillary sinus surgery with an endoscopic view from an oroantral fistula and then, in 1922, Spielberg started to use antroscopes to access the maxillary sinus through the inferior meatus. Maltz coined the term “sinuscopy” in 1925.8 However, the lack of antibiotics and proper instruments, the inadequate anesthesia, and the poor anatomic knowledge linked these surgeries to increased fatal complications. Mosher wrote in 1929: “… any surgery in this region could be simple, but it has proven to be one of the easiest to kill a patient.” For this reason, the endonasal approach remained in the darkness until the 1980s.3,4

Back then, these scopes were bad in terms of optical quality, field of view, and illumination, as they were using electric bulbs. No wonder that the introduction of the microscope in sinus surgery by Heermann in 1958 stopped the expansion of the endoscopic surgery.9 The revolution came with the rod optic endoscope developed by Hopkins in the 1960s, which dramatically increased the optical quality.10 Thereafter, Karl Storz in Germany created angled endoscopes and later wide-angled endoscopes offering a huge field of view. When Hopkins and Storz shared their know-how, the endoscopes got cold light and, thus, the possibility of the endonasal surgery became a reality.11

In 1660, Schneider realized that the mucus of the nose is produced by the mucosa lining of the paranasal sinus, and not, as had been thought until then, by the brain.12 However, it was not until the 20th century that the idea to treat some nose diseases by operating the paranasal sinuses increased.13 This idea started when it was described how the nose had an important function filtrating, humidifying, and warming up the air, thanks to the function of mucociliary clearance and autonomic system. Golding-Wood, in 1963, described how the glands of the nasal mucosa, as well as the vessels, have a direct parasympathetic innervation, leading to a direct increase of nasal secretions via transudation and exsudation when stimulated.14

Messerklinger, in Austria, was one of the pioneers of the endoscopic assessment of the pathophysiology of the lateral nasal wall. He started to explore the function of the nose with the endoscope instead of the microscope, to identify why the sinuses were blocked or from where the mucous was draining, allowing one of his pupils, Stammberger, to develop and spread the concept of minimally invasive surgery of the paranasal sinuses, nowadays known as functional endoscopic sinus surgery.15,16

Computed tomography was developed in 1972, while magnetic resonance imaging arrived in 1977. It took many years to introduce a preoperative scan as a routine assessment for all bony landmarks and the extension of chronic inflammatory disease, and it considerably improved the indications for endonasal surgery. Stammberger and Kennedy started to spread the Messerklinger concepts worldwide16,17—basically, the enlargement of narrow spaces to provide aeration and drainage of the paranasal sinuses through the natural ostia while preserving the surrounding mucosa as much as possible. MacKay and Lund established the systematic evaluation of radiologic studies before surgery, proposing a staging score (the Lund–Mackay score).18,19

Technological development introduced specific surgical instruments, such as powered instrumentation known as shavers or microdebriders,20 and navigation systems. The first experience in computer-assisted sinus surgery was published by Anon et al in the 1990s.21

Apart from inflammatory diseases, benign tumors were started to be removed endoscopically. In 1990, Waitz and Wigand published a large case series of patients with inverted papilloma treated exclusively with an endonasal approach.22 This did not happen without a lot of discussion. In the mid-1990s, small juvenile angiofibromas were also approached endoscopically.23–25 Meanwhile, extended angiofibromas, reaching the infratemporal fossa, the cavernous sinus, or the parapharyngeal space, are approached endoscopically.26

The possibility to assess the skull base through the nose started with the closure of small iatrogenic cerebrospinal fluid (CSF) leaks by Wigand in 1981.27 Today, most CSF leaks are being closed endoscopically.

The transsphenoidal route to the pituitary was described in 1907, but it was abandoned due to technical difficulties. In the 1960s, Hardy started to perform transsphenoidal surgery using a microscope.28 Jankowski et al published the first series on endoscopic pituitary surgery procedures in 1992,29 and in 1996, Jho and Carrau described and standardized the procedure.30 Cappabianca and de Divitiis coined the term “functional endoscopic pituitary surgery.”31

Since the first interdisciplinary congress of endoscopic surgery of skull base in 2005, the number of interdisciplinary teams (mainly ENT and neurosurgery) has increased exponentially and more diseases are treated transnasally.4 The initial experience with the closure of CSF leaks combined with the increasing experience in endoscopic pituitary surgery gave way to an increasing collaboration between rhinologists and neurosurgeons, opening their minds.

Slowly but steadily, the modern endoscopic skull base surgery was developed in some centers, not without controversies, particularly when malignant sinonasal tumors were also started to be removed through an endoscopic approach.3 As always in medicine, this progression occurred stepwise. First, small amenable tumors, and then, with increasing experience, larger tumors were approached. Of course, the idea to treat malignant tumors solely through the nose was scary due to the narrow entrance to the surgical field, the difficulties to perform a “monoblock” resection, and last but not the least, the problems in achieving tumor-free margins. This led some authors to debulking or fragmenting (“disassembling”) the tumors.3 In the long term, endoscopic approaches seem to achieve similar outcomes and survival rates as open ones.32–34

Technology is increasingly allowing the expansion of the endoscopic nasal surgery, as is the number of rhinologists and neurosurgeons involved in endoscopic multidisciplinary teams. High-definition cameras have replaced traditional cameras. Furthermore, the advent of high-definition monitors, translating into an increased pixel density, offers the surgeon better color, contrast, resolution, and peripheral visualization of the surgical field.

This, together with the increasing experience of the teams, particularly the groups from Pittsburgh (Kassam, Carrau and coworkers) and Italy (Cappabianca, Castelnuovo and Locatelli, Frank and Pasquini), led to the development of different surgical corridors in the coronal and sagittal planes, with the rule of never to cross nerves and/or the internal carotid artery, and expanded the endonasal corridors, as can be studied in the different chapters of this book, from the anterior skull base to the middle and posterior cranial fossae.

The major challenge encountered was in reconstructing those large skull base defects left after extended approaches. Postoperative CSF leakages, with the risk of ascending bacterial meningitis subsequently increasing, were among the most frequent complications feared. To minimize that risk, the incorporation of pedicle flaps into the armamentarium of skull base reconstruction can be considered a milestone. The nasoseptal flap described by Hadad et al in 2006 definitely opened the door to more transnasal surgeries of the skull base, reducing the risk of CSF leaks significantly.35 Since then, other local nasal flaps such as lateral wall flap and regional flaps, for example, the pericranial flap, were extremely helpful to reconstruct even after endoscopic resections of large tumors.

The aim of this book is to recollect and thoroughly describe all anatomic aspects and possibilities of transnasal endoscopic surgery of the paranasal sinus, as this will serve to understand more extended approaches. Here, important vascular structures, such as the ethmoidal arteries or the internal maxillary and sphenopalatine artery, plus its branches, deserve a chapter on its own. The next block deals with the anterior cranial fossa, analyzing all the different approaches to the anterior skull and brain, from the transcribriform to the transorbital approach, including also the sella and suprasella spaces, and the cavernous sinus. We then move laterally toward the middle cranial fossa, focusing on the quadrangular space, the intrapetrous artery, and the anterior petrosectomy. The next group of chapters is related to the clivus and posterior cranial fossa corridors, including the retrosellar, the transclival, the craniovertebral junction, the transcondylar, and the jugular foramen approaches. After that, the approaches to the pterygopalatine and infratemporal fossa are described, including the nasopharyngectomy. The last chapters address combined endoscopic and transcranial approaches, basic landmarks in expanded endoscopic skull base surgery, particularly bony landmarks and the internal carotid artery, and reconstruction techniques.

Related posts:

Chapter 2 Three-Dimensional Anatomy of the Skull Base: The Ventral Pathway Chapter 3 Endoscopic Lateral Nasal Wall and Anterior and Posterior Ethmoid Sinus Dissection Chapter 13 Cavernous Sinus Approach Chapter 22 The “Far Medial” (Transcondylar/Transtubercular) Approach to the Inferior Third of the Clivus Chapter 28 Retrosigmoid–Transclival Approach Chapter 16 The Anteromedial Corridor via the Expanded Endonasal Approach: The “Front Door to Meckel′s Cave”

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