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Deputy Director, Dartmouth College Geisel School of Medicine

Prevedello the classification of endonasal approaches to the ventral skull base is based on anatomic relationships and orientation in radiologic planes (Table 51 treatment 3rd degree hemorrhoids buy 300mg combivir free shipping. The sagittal plane extends from the frontal sinus to the second cervical vertebra treatment zone guiseley buy combivir american express. The coronal plane is divided into three planes corresponding to the anterior medicine dropper purchase combivir 300mg fast delivery, middle, and posterior cranial fossae. Individual surgical modules vary greatly in anatomic complexity, technical difficulty, and potential risk to neurovascular structures. To address these issues, we have devised a training program that classifies endonasal surgical modules into five levels that are incremental and modular (Table 51. Since the introduction of the endoscope, there has been an evolution of surgical techniques in all of the surgical disciplines from maximally invasive open approaches to minimally invasive endoscopic approaches. Cranial base surgery is the latest surgical specialty to embrace endoscopic techniques and it is revolutionizing the practice of skull base surgery. It is important to realize, however, that endonasal endoscopic skull base surgery is maximally invasive; it has extended the limits of cranial base surgery. The major concept of endonasal surgery is not the use of the endoscope but the choice of a nasal corridor for ventral skull base pathology. Endonasal endoscopic approaches have been applied to the treatment of extrasellar pituitary tumors, sinonasal neoplasms, clival tumors, expansile lesions of the petrous apex, aneurysms, and even the upper cervical spine. Patient Selection/Indications the selection of a surgical approach is predicated on multiple factors: diagnosis, sites of involvement, extent of disease, prior treatment, medical comorbidities, surgical expertise, reconstruction, tumor vascularity and consistency, and patient preference. There must exist a dedicated surgical team (otolaryngology and neurosurgery) with adequate surgical expertise and resources (equipment, staff) to perform extended endonasal procedures. The surgical team needs to understand endonasal skull base anatomy and have mastery of hemostatic and reconstructive techniques. The choice of an endonasal approach may be limited by the ability to perform a complete resection and the ability to deal with potential complications (vascular injury), reconstructive needs (dural reconstruction), and the duration of the surgery (impact on the patient and surgeon). The guiding principle of endonasal skull base surgery is to minimize displacement of normal neural and vascular structures. Tumors that are situated superolateral to the optic nerves or require transposition of a major vessel are examples of situations in which a different surgical corridor or the use of multiple corridors must be considered. Tumors that are located posterior to the pituitary stalk may be accessed using a pituitary transposition with preservation of pituitary function. For high-grade malignancies, nonoperative therapy is usually selected although there may be a role for palliative debulking of bulky tumors or limited resection of residual tumor following radiochemotherapy. This patient had a keratinizing nasopharyngeal carcinoma (Type 1) and underwent endoscopic debulking of the neoplasm to relieve a sixth cranial nerve palsy prior to radiochemotherapy. When a definitive diagnosis is not apparent from imaging and the treatment plan may be altered. For sinonasal neoplasms with skull base or orbital involvement, the ability to provide informed consent to the patient and the choice of primary therapy (surgery versus radiochemotherapy) is dependent on the grade of the neoplasm. For deeply situated tumors (middle cranial fossa), an endonasal approach provides the least invasive approach for diagnosis, and the extent of tumor resection will depend on a frozen histologic section. In preparation for surgery, the preoperative imaging is obtained using an image-guidance protocol. An intraoperative navigational system is routinely used in all endonasal surgeries to help identify key anatomic landmarks and the limits of resection.

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Surgical approaches to the anterior skull base have evolved since an initial paper in 1954 by Smith1 described resection of a frontal sinus tumor medicine you can overdose on buy combivir 300mg line. Between 1963 and 1973 symptoms 7dp5dt generic 300mg combivir with mastercard, Ketcham4 medicine 369 order combivir line,5 demonstrated clearly that surgery in this area, although associated with significant morbidity, improved the likelihood of cure of malignant tumors. Since that time, numerous surgical techniques have been introduced to extend or improve anatomic access for resection or reconstruction, and/or to reduce functional or aesthetic morbidity. Small transfacial incisions that supplement a bicoronal craniotomy incision are widely used6 and, increasingly, endoscopic and endoscopic-assisted approaches are being perfected for selected cases, as reviewed by Har-El. Compared with a generation ago, improved local control and survival rates have been documented, and the incidence of severe morbidity and mortality has been reduced to much lower than 5%. Thus, a purely rhinal and often endoscopic approach is preferred unless this would significantly limit the extent of tumor resection or preclude adequate repair of the anterior skull base. Identification of such limitations of a rhinal approach requires familiarity with surgical anatomy, the natural history of neoplastic diseases of the area, and the efficacy of adjuvant therapies. Indications Although extensive bacterial or fungal infections of the anterior or lateral skull base occasionally require combined transcranial and rhinal approaches, tumors far more frequently require these combined approaches and are the focus of this review. Tumors that may require anterior skull base resection include selected malignant tumors of the paranasal sinuses that extend superiorly through the cribriform plate, ethmoid roof, and planum sphenoidale or posteriorly through the posterior wall of the frontal sinus; benign and malignant meningiomas that involve the same areas; and selected benign tumors or tumorlike lesions such as orbital apex schwannomas, large nasal tumors such as juvenile angiofibromas and inverted papillomas, and occasional encephaloceles and mucoceles. The goals of anterior skull base surgery for tumors have remained constant throughout the continuing evolution of surgical and radiation oncology techniques. Segregation of intracranial contents from the contaminated paranasal sinuses, reducing the incidence of meningitis 4. Improved aesthetic outcome Contraindications to aggressive surgical resection include tumor extension that precludes resection of tumor with negative margins. Additional contraindications include distant metastatic disease unlikely to respond to chemotherapy and patient medical fragility. Specific indications for craniotomy or a combined procedure over a rhinal approach alone include the following: 1. Tumor involvement superior to the orbit (and lateral to the ethmoid roof) in cases in which preservation of the orbit is anticipated. Dural enhancement extends laterally (small white arrows), beyond the reach of an endoscopic approach. Inaddition, bilateral left-greater-than-right extension of tumor into the orbit is seen (white arrows). Some might have resected this lesion endoscopically, butthesiteoftumorprecludedtheuseofarobustregionalmucosal B flap. Resectable tumor attached to the dorsal or lateral aspects of the optic nerve, optic chiasm, or the intracranial internal carotid artery and its branches 3. Tumor widely involving subfrontal dura, especially over the orbital roofs, such that watertight closure is precluded. In our experience, when the patient has full extraocular motility on preoperative clinical examination, one can usually preserve the orbit. If there is diplopia solely because of mass effect leading to proptosis and interference with extraocular muscle function but without radiologically evident extension of tumor into orbital fat, then the orbit also is likely to be able to be preserved. Extension of tumor superiorly through the orbital roof limits tumor resection from below, mandating craniotomy. The exception to mandated craniotomy is tumor involvement of the orbit sufficiently extensive to warrant exenteration, in which case tumor that is superior to the orbit can be removed transorbitally. Many feel, as do we, that the orbit can be functionally preserved in an oncologically sound fashion if there is no significant involvement of the orbital fat, even if the orbital periosteum is involved with the tumor.

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Bilateral sinus disease requires more comprehensive clearance of the sinuses treatment quad strain buy 300 mg combivir, including bilateral sphenoethmoidectomies and medications 1 cheap combivir 300 mg otc, if involved symptoms zithromax cheap combivir generic, clearance of the frontal recesses. In patients with frontal sinus fungal disease, meticulous clearance of the frontal recess is performed by removing all cells, obstructing polyps, and mucus so that the frontal ostium and frontal sinus can be visualized adequately. If the pathologic process causing ongoing nasal polyp formation cannot be managed with the size of the natural ostium achieved with frontal recess clearance, there is little to be gained from further conservative surgery. When the ostium is, 3 3 3 mm, obstruction occurs readily in the postoperative period. Several other clinical and anatomical considerations are taken into account in the selection of surgical procedures to Operating with Poor Landmarks In the setting of severely polypoid fungal disease, critical anatomical landmarks, such as the uncinate process, bulla ethmoidalis, and ground lamella, as well as the middle and superior turbinates, may be markedly altered or obscured, particularly during revision surgery. In such instances, computer-aided surgical navigation systems may offer some benefit and should be planned for preoperatively. However, beyond this, several techniques can be used to safely clear residual disease in cases with altered landmarks. Surgical Management 369 It is always prudent to clearly identify the maxillary sinus ostium as an initial landmark in primary as well as revision surgery. The middle meatal antrostomy should be created widely into the posterior fontanelle in cases with large polyps and thick fungal mucus. The 30-degree endoscope should be employed and directed toward the lateral nasal wall for this step. In the absence of a clear free edge of the uncinate process, the insertion of the inferior turbinate can help guide the surgeon to the position of the ostium, which is located immediately superior to the midportion of this turbinate. A curved suction or rightangle ball probe can be used to palpate for the position of the ostium and to penetrate into the maxillary sinus by advancing the tip in an inferolateral direction, roughly 45 degrees from the horizontal plane, just above the insertion of the inferior turbinate. The ostium is then enlarged posteriorly into the area of the fontanelle using throughcutting Blakesley forceps and anteriorly using backbiting forceps to clear any residual uncinate. The position of this ostium can now be used as a landmark, as can the junction of the medial orbital floor and the lamina papyracea. If this junction is followed posteriorly in a horizontal plane, this should take the dissection onto a point on the anterior face of the sphenoid, which approximates the inferior third to middle third of the sphenoid sinus. For this latter reason, the sphenoid should be addressed before dealing with any partially resected ethmoid cells. In the presence of a superior turbinate, the sphenoid ostium can be found medial to the inferior third of this turbinate. Other methods of locating the ostium are measuring 12 mm superior to the rim of the posterior bony choana and measuring 7 cm from the anterior nasal spine in a plane rising 30 degrees above the floor of the nasal cavity. If the ostium cannot be visualized, the sinus can be entered using the blunt end of a Freer elevator in the expected position of the ostium. However, in cases of complex anatomy, exuberant disease, or previous surgery with local scarring, the drainage pathway may be difficult to localize intraoperatively. Dissecting instruments can then be precisely placed into this corridor and the surrounding cells fractured away. The Maxillary Sinus Grading of Mucosal Disease the extent of maxillary sinus disease is graded intraoperatively. After the uncinectomy and middle meatal antrostomy, a 70-degree endoscope is used to visualize the maxillary sinus contents through the natural ostium. Polyps and thick eosinophilic mucus are cleared entirely from the sinus to improve reepithelialization and reciliation. Middle Meatal Antrostomy the "swing-door" technique of uncinectomy achieves complete and safe removal of the uncinate process and exposes the natural ostium of the maxillary sinus. The right-angled ball probe is then placed behind the uncinate process, and the midportion of the uncinate process is fractured anteriorly flush with the lateral nasal wall.

Diseases

• Al Gazali Khidr Prem Chandran syndrome
• Parathyroid cancer
• Acute non lymphoblastic leukemia (generic term)
• Swyer James and McLeod Syndrome
• Spontaneous periodic hypothermia
• Color blindness
• Otospondylomegaepiphyseal dysplasia
• Perimyositis
• Synesthesia
• Ossicular malformations, familial