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Cerebrospinal fluid (CSF) leakage is a common complication associated with endoscopic endonasal skull-base surgery (EESBS). Postoperative mobilization-associated postural changes are considered to cause CSF leakage. However, no study has demonstrated a robust relationship between postural changes and CSF leakage. We used upright computed tomography (CT) to clarify the effects of postural changes on the reconstructed skull base (RSB) after EESBS. Thirty patients who underwent EESBS at our institution were prospectively included, and their upright and supine CTs were compared to measure morphological changes in the RSB. Patient clinical data were also collected from medical charts and surgical videos, and their relationships with morphological changes were assessed. In upright CTs, the RSB shifted intracranially by 0.94 (0.0-2.9) mm on average. This shift was larger in cases with lesions extending to the sphenoid sinus, dural defects, intraoperative pulsation of the RSB, and large bone windows. The direction of the change was opposite to intuitive movement driven by gravity because of reduced intracranial pressure in the sitting position. Thus, these shifts can be directly associated with postoperative CSF leakage caused by reconstruction material displacement. Skull-base reconstruction and postoperative postural management accounting for these morphological changes may be necessary for preventing CSF leakage.

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Background: Over the past two decades, endoscopic endonasal skull base surgery (EESBS) has revolutionized the treatment of skull base tumors by enabling minimal access to resect significant pathologies such as meningiomas, pituitary adenomas, and chordomas. Despite its efficacy, complications such as cerebrospinal fluid (CSF) leak pose significant challenges, with an average incidence of 8.9% following EESBS. Therefore, our study aims to investigate the risk factors associated with postoperative CSF leak after employing an endoscopic endonasal approach for skull base surgery, focusing on patients treated at King Abdul-Aziz Medical City in Jeddah and King Abdullah Medical City in Makkah, Saudi Arabia. Methods: A retrospective review of patients who underwent an endoscopic endonasal approach for the resection of intradural skull base pathology between January 2016 and December 2022 was performed with a total of 51 patients. Basic demographic data were collected, along with patient comorbidities, presenting symptoms, tumor pathology, tumor site, the extent of resection, and outcomes. Results: 51 participants were analyzed, with a mean age of 43.41. Male participants comprised (58.8%), while headaches were the most common symptom (74.5%), followed by visual disturbances (51.0%). Nonsecretory tumors predominated, primarily located in the sellar and suprasellar regions (58.8%). Gross total resection was performed in the majority (56.9%), with a 9.8% incidence of postoperative CSF leak. Notably, all four patients with CSF leak experienced preoperative headaches. Hypertension was prevalent in Cases 1 and 4, with Case 4 having a history of neurological disease and radiation therapy. Anterior skull base tumors were most frequent in Cases 3 and 4. Conclusion: The incidence of CSF leakage after surgery in this study was similar to that previously reported. It is worth noting that repeated surgeries may increase the risk of postoperative CSF leakage. Therefore, it is important to carefully evaluate the surgical approach for tumor removal and skull base reconstruction, considering the tumor characteristics and the patient's overall condition.

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OBJECTIVE: Resections of symptomatic Rathke's cleft cysts (RCCs) are mainly performed via an endonasal transsphenoidal approach. However, there is a lack of equivalent data in current literature concerning transcranial keyhole approach in the treatment of RCCs. In order to find general recommendations for the surgical treatment of RCCs also with regard to recurrence, the object of this study is the analysis and comparison of both techniques. METHODS: Twenty-nine patients having been surgically treated between January 2004 and August 2019 were retrospectively analysed. The transsphenoidal approach was chosen in 16 cases and the transcranial keyhole approach in 13 cases. Both surgical techniques were analyzed and compared concerning preoperative symptoms and cyst characteristics, complications, surgical radicality, endocrinological and ophthalmological outcome and recurrences in patients´ follow up. RESULTS: The postoperative outcome of both techniques was identic and showed highly satisfying success rates with 92% for neurological deficits, 82% for endocrinological dysfunctions and 86% for visual deficits. In contrast, momentous postoperative complications were significantly more likely after transsphenoidal operations. After a mean follow-up time of 5.7 years, the recurrence rates of both cohorts were the same with 0% each. CONCLUSIONS: Regarding its equal outcome with its lower complication rate, the authors suggest using the supraorbital keyhole approach for RCCs whose anatomical configuration allow both techniques. Yet, the decision should always consider the surgeon's personal experience and other individual patient characteristics. Further studies with higher numbers of cases and longer follow-up periods are necessary to analyse the effect of the selected approach on recurrence.

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Optic pathway gliomas (OPGs) are rare pediatric tumors that pose significant challenges in management due to their location and clinical manifestations. Traditional transcranial approaches have been the mainstay for surgical intervention, but recent advancements in endoscopic endonasal transsphenoidal surgery offer a less invasive alternative. Here, we present a case of a 10-year-old female child with neurofibromatosis type-1 and an aggressive OPG who underwent endoscopic endonasal transsphenoidal debulking surgery. The pre-operative evaluation confirmed complete vision loss, and imaging revealed tumor progression. The surgery was successful, resulting in a subtotal resection and a diagnosis of pilocytic astrocytoma, WHO grade 1. Post-operative assessments showed no complications. This case highlights the feasibility of the endoscopic endonasal transsphenoidal approach for OPGs and emphasizes the importance of careful patient selection and multidisciplinary collaboration in achieving successful outcomes for these challenging tumors.

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OBJECTIVE: The aim of this study was to investigate the impact of collagen matrix on reconstructive material selection and postoperative complications in endoscopic endonasal skull base surgery. METHODS: The authors retrospectively reviewed the data of consecutive patients who underwent purely endoscopic endonasal skull base surgery from January 2015 to March 2023. Intraoperative CSF leakage was classified according to the Esposito grade, and skull base repair was tailored to the leakage grade. The patients were divided into two groups: before (group A) and after (group B) collagen matrix implementation. The rates of autologous graft harvesting (fat, fascia, and nasoseptal flap), postoperative CSF leakage, and donor-site complications were compared between the two groups. RESULTS: In total, 270 patients were included. Group A included 159 patients and group B included 111 patients. There were no differences in patient characteristics, including age, pathology, and Esposito grade, between the two groups. The overall fat usage rate was significantly higher in group A (63.5%) than in group B (39.6%) (p = 0.0001), and the fascia usage rate was also significantly higher in group A (25.8%) than in group B (4.5%) (p < 0.0001). The nasoseptal flap usage rate did not differ between group A (32.7%) and group B (30.6%) (p = 0.79). Postoperative CSF leakage was similar between the two groups (0.63% in group A vs 1.8% in group B, p = 0.57), and the overall rate of CSF leakage was 1.1%. Donor-site complications occurred in 3 patients in group A, including 1 abdominal hematoma, 1 delayed abdominal infection, and 1 fluid collection after fascia lata harvesting. CONCLUSIONS: Collagen matrix implementation significantly decreased autologous graft harvesting without increasing postoperative CSF leakage, contributing to less invasive surgery.

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Several traumatic and non-traumatic defects in the anterior base of the skull require incessant reconstruction to stop the leakage of cerebrospinal fluid (CSF). Reconstruction of these defects at the earliest is essential to achieve an uncomplicated recovery. Various innovations in surgical procedures are seen contemporarily in reconstructing the weaknesses in the anterior part of the skull base. Multilayer grafting techniques successfully repair minor dural defects, while significant dural defects require pedicled vascularized grafts for reconstruction. Using nasoseptal flaps (NSFs) has drastically lowered the instances of CSF leaks in significant dural defects. The rescue flap is an advancement in the approach of the NSF, which was discovered in 2011. This flap is made in a downward direction with the formation of a posterior superior incision so that it does not interfere with the mucosal flap. A small incision is made at the ostium of the sphenoid bone, which is brought into the anterior aspect of the superior nasal septum. The mucosa is elevated inferiorly through the ostium of the sphenoid bone, so some septal branch of the sphenopalatine artery is preserved. In this way, the vascular supply is protected. However, in cases of CSF leak during operations, this rescue flap is reverted into an atypical and standard NSF for reconstructing the base of the skull. This rescue flap technique gives a binaural approach to sella in a way that does not compromise the pedicle during tumor removal. This rescue flap significantly decreases the duration of care in the post-operative phase and improves the cost efficiency of the surgery by avoiding donor site morbidity.

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While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications.

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Recurrent nasopharyngeal carcinoma (rNPC) presents unique challenges as reirradiation comes with significant treatment-related morbidity in swallowing, middle ear function, and large-vessel integrity. Advances in endoscopic technology have made surgery for rNPC an increasingly viable option for select patients and may play a role in providing a better quality of life to patients with this challenging disease. In carefully selected patients, endoscopic and open surgical approaches may provide comparable disease control while mitigating long-term treatment-related morbidity.

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Various types of mucosal flaps can be used for skull base reconstruction after endoscopic endonasal skull base surgery (EESS). Preventing postoperative cerebrospinal fluid (CSF) leakage is essential. Flap creation during revision surgery can be problematic. We present a patient in whom a posterior septal nasal floor flap (PS-NF) was successfully reused for reconstruction after multiple reoperations for pituitary tumor resection. A 22-year-old female underwent EESS for resection of a pituitary tumor and experienced multiple recurrences after repeated operations. For the third recurrence, a skull base surgery team comprising otolaryngologists and neurosurgeons performed a binostril combined transnasal/transseptal approach and used a PS-NF for reconstruction. For the fourth recurrence, a PS-NF was successfully taken down and reused for reconstruction. No postoperative CSF leakage or intranasal complications occurred. Skull base reconstruction using a PS-NF is feasible and preserves the mucous membrane of the nasal septum and the morphology of the nasal cavity. PS-NF takedown and reuse is an option for revision EESS for recurrent pituitary tumors.

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The functional outcome, quality of life, and patient feedback related to a chosen treatment approach in skull base surgery have become a subject of interest and focused research in recent years. The current advances in endoscopic optical imaging technology and surgical precision have radically lowered the perioperative morbidity associated with skull base surgery. This has pushed toward a higher focus on patient-reported outcomes (PROs). It is now critical to ensure that the offered treatment plan and approach align with the patient's preferences and expectations, in addition to the surgeon's best clinical judgment and experience. PROs represent a view that reflects the patient's own thoughts and perspective on their condition and the management options, without input or interpretations from the surgeon. Having PRO data enables patients the opportunity to learn from the experiences and perspectives of other patients. This input empowers the patient to become an active participant in the decision-making process at different stages of their care. An in-depth PRO evaluation requires specific validated tools and scoring systems, namely the patient-reported outcomes measures (PROM) tools. In this review, we discuss the currently available skull-base-related PROs, the assessment tools used to capture them, and the future trends of this important topic that is in its infancy.

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BACKGROUND: Neurosurgical procedures are complex and require years of training and experience. Traditional training on human cadavers is expensive, requires facilities and planning, and raises ethical concerns. Therefore, the use of anthropomorphic phantoms could be an excellent substitute. The aim of the study was to design and develop a patient-specific 3D-skull and brain model with realistic CT-attenuation suitable for conventional and augmented reality (AR)-navigated neurosurgical simulations. METHODS: The radiodensity of materials considered for the skull and brain phantoms were investigated using cone beam CT (CBCT) and compared to the radiodensities of the human skull and brain. The mechanical properties of the materials considered were tested in the laboratory and subsequently evaluated by clinically active neurosurgeons. Optimization of the phantom for the intended purposes was performed in a feedback cycle of tests and improvements. RESULTS: The skull, including a complete representation of the nasal cavity and skull base, was 3D printed using polylactic acid with calcium carbonate. The brain was cast using a mixture of water and coolant, with 4 wt% polyvinyl alcohol and 0.1 wt% barium sulfate, in a mold obtained from segmentation of CBCT and T1 weighted MR images from a cadaver. The experiments revealed that the radiodensities of the skull and brain phantoms were 547 and 38 Hounsfield units (HU), as compared to real skull bone and brain tissues with values of around 1300 and 30 HU, respectively. As for the mechanical properties testing, the brain phantom exhibited a similar elasticity to real brain tissue. The phantom was subsequently evaluated by neurosurgeons in simulations of endonasal skull-base surgery, brain biopsies, and external ventricular drain (EVD) placement and found to fulfill the requirements of a surgical phantom. CONCLUSIONS: A realistic and CT-compatible anthropomorphic head phantom was designed and successfully used for simulated augmented reality-led neurosurgical procedures. The anatomic details of the skull base and brain were realistically reproduced. This phantom can easily be manufactured and used for surgical training at a low cost.

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Endoscopic endonasal skull base surgery is a promising alternative to transcranial approaches. However, standard instruments lack articulation, and thus, could benefit from robotic technologies. The aim of this study was to develop an ergonomic handle for a handheld robotic instrument intended to enhance this procedure. Two different prototypes were developed based on ergonomic guidelines within the literature. The first is a forearm-mounted handle that maps the surgeon's wrist degrees-of-freedom to that of the robotic end-effector; the second is a joystick-and-trigger handle with a rotating body that places the joystick to the position most comfortable for the surgeon. These handles were incorporated into a custom-designed surgical virtual simulator and were assessed for their performance and ergonomics when compared with a standard neurosurgical grasper. The virtual task was performed by nine novices with all three devices as part of a randomised crossover user-study. Their performance and ergonomics were evaluated both subjectively by themselves and objectively by a validated observational checklist. Both handles outperformed the standard instrument with the rotating joystick-body handle offering the most substantial improvement in terms of balance between performance and ergonomics. Thus, it is deemed the more suitable device to drive instrumentation for endoscopic endonasal skull base surgery.

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Considering quality of life (QOL) is critical when discussing treatment options for patients undergoing endoscopic endonasal skull base surgery (EESBS) for cancers at the base of the skull. Several questionnaires have been developed and validated in the last 20 years to explore QOL in this patient population, including the Anterior Skull Base Questionnaire, Skull Base Inventory, EESBS Questionnaire, and the Sino-Nasal Outcome Test for Neurosurgery. The Sino-Nasal Outcomes Test-22 and Anterior Skull Base Nasal Inventory-12 are other tools that have been used to measure sinonasal QOL in anterior cranial base surgery. In addition to pathology-related perturbations in QOL endoscopic surgical options (transsellar approaches, anterior cranial base surgery, and various reconstructive techniques) all have unique morbidities and QOL implications that should be considered. Finally, we look ahead to new and emerging techniques and tools aimed to help preserve and improve QOL for patients with anterior cranial base malignancies.

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BACKGROUND: One of the major complications in endoscopic endonasal skull base surgery (EESBS) is postoperative cerebrospinal fluid (CSF) leaks. Recently, EESBS has been applied to various skull base diseases as well as more complicated cases influenced by previous treatment with or without various comorbidities. AIMS/OBJECTIVES: This study aimed to assess the factors that influence the results of postoperative CSF leak after EESBS with mixed patient backgrounds. MATERIALS AND METHODS: We conducted a retrospective analysis of the clinical records of patients undergoing EESBS in our institution from 2012 to 2017. RESULTS: Out of a total of 230 cases of EESBS, 11 (4.8%) suffered from postoperative CSF leakage. The rate of CSF leakage for pituitary adenoma, Rathke's cleft cyst, chordoma, and meningioma was 3.5%, 0%, 3.6% and 8.0%, respectively. Multiple variate analysis revealed that repeated surgery (p = .008) and intraoperative CSF leak (p = .044) were significant risk factors for postoperative CSF leakage. CONCLUSIONS AND SIGNIFICANCE: The rate of postoperative CSF leakage in this study was comparable to previous reports, and repeated surgery may increase postoperative CSF leakage. The surgical strategy for tumor removal as well as skull base reconstruction should be given careful consideration according to tumor pathology and the patient's condition.

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A 70-year-old Japanese man undergoing remission induction therapy for acute monocytic leukemia (AML-M5b) developed fever and headache, and was started on antibiotics and liposomal amphotericin B (L-AMB). There was no improvement, and computed tomography and contrast-enhanced magnetic resonance imaging revealed acute rhinosinusitis and brain abscess. Successful endoscopic endonasal surgery was performed at this point, providing drainage for the rhinosinusitis and abscess. Histopathological findings showed the mucormycosis.

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BACKGROUND: Surgical management of the superior turbinate (ST) is required to access the sella in endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenoma. Two common ST management techniques include partial resection of the ST (PRST) and intentional lateralization of the ST (ILST). Given the concentrated distribution of the olfactory nerve fibers on the medial surface of the ST, in this study we aimed to ascertain whether PRST worsens the objective olfactory outcome when compared with ILST. METHODS: A retrospective, propensity score-matched cohort study was performed at a tertiary referral center. A total of 232 adult patients undergoing EETS for pituitary adenoma were analyzed. The threshold test (STT) and the 12-item identification test (SIT-12) from "Sniffin' Sticks" were administered for separate nostrils preoperatively and 6 months postoperatively. RESULTS: Of 232 patients, 109 had right-sided PRST and 123 received right-sided ILST. Propensity score matching-controlling for olfactory-related confounding factors, including gender, age, medical comorbidities, surgical technique, and preoperative olfaction-resulted in 74 matched pairs. When comparing the 6-month postoperative olfactory performance of the right nostril, the STT score was significantly lower in the PRST group than the ILST group (p = 0.036, η2 for effect size estimate = 0.030), but the SIT-12 scores were similar in the 2 groups (p = 0.325). Overall, the olfactory outcomes for the right nostril did not qualitatively differ between the PRST and ILST groups (p = 0.401). CONCLUSION: Despite its association with threshold impairment, PRST in EETS does not seem to carry an additional risk of postoperative olfactory dysfunction.

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BACKGROUND: COVID-19 pandemic has disrupted the global health systems worldwide. According to the tremendous rate of interhuman transmission via aerosols and respiratory droplets, severe measures have been required to contain contagion spread. Accordingly, medical and surgical maneuvers involving the respiratory mucosa and, among them, transnasal transsphenoidal surgery have been charged of maximum risk of spread and contagion, above all for healthcare professionals. METHOD: Our department, according to the actual COVID-19 protocol national guidelines, has suspended elective procedures and, in the last month, only three patients underwent to endoscopic endonasal procedures, due to urgent conditions (a pituitary apoplexy, a chondrosarcoma causing cavernous sinus syndrome, and a pituitary macroadenoma determining chiasm compression). We describe peculiar surgical technique modifications and the use of an endonasal face mask, i.e., the nose lid, to be applied to the patient during transnasal procedures for skull base pathologies as a further possible COVID-19 mitigation strategy. RESULTS: The nose lid is cheap, promptly available, and can be easily assembled with the use of few tools available in the OR; this mask allows to both operating surgeon and his assistant to perform wider surgical maneuvers throughout the slits, without ripping it, while limiting the nostril airflow. CONCLUSIONS: Transnasal surgery, transgressing respiratory mucosa, can definitely increase the risk of virus transmission: we find that adopting further precautions, above all limiting high-speed drill can help preventing or at least reducing aerosol/droplets. The creation of a non-rigid face mask, i.e., the nose lid, allows the comfortable introduction of instruments through one or both nostrils and, at the same time, minimizes the release of droplets from the patient's nasal cavity.

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A 68-year-old female was admitted to our hospital with right-sided hemianopsia. Magnetic resonance imaging (MRI) demonstrated a well-enhanced tuberculum sellae region tumor. The patient underwent surgical tumor resection via an extended endoscopic endonasal trans-sphenoidal approach and the tumor was totally removed. The mass was extremely soft and there was no clear attachment between it and the dura mater. Furthermore, the histopathological findings obtained for the tumor during intra-operative rapid diagnosis were divergent from typical meningioma. We therefore diagnosed the tumor intra-operatively as a pituitary adenoma. However, the post-operative pathological diagnosis for the tumor was chordoid meningioma (CM). CM is a rare subtype of meningioma, and most of such tumors arise in the convexity. In the preoperative MRI in the present case, meningioma was suspected; however, since we did not consider CM for differential diagnosis, we failed to reach an accurate diagnosis during the operation. Tuberculum sellae CM is very rare, and only a few cases have been reported previously. The surgical strategy will differ greatly depending on whether the tumor is a meningioma or a pituitary adenoma, especially when treatment involves the dura mater. The pre and/or intra-operative diagnosis is thus very important for developing an accurate treatment strategy. We report here the details of our rare case and describe the intra-operative features of tuberculum sellae CM.

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BACKGROUND: The differences between 3-dimensional (3D) high definition (HD) and 2-dimensional (2D) 4-K ultra-HD (4K) endoscopy and their respective advantages remain unclear. OBJECTIVE: To evaluate the utility of these endoscopy systems in endonasal skull base surgery. METHODS: Consecutive series of endoscopic endonasal surgeries performed after introduction of 3D/HD and 2D/4K systems (July 2017) were retrospectively evaluated. Sporadic cases treated with either system, or a conventional 2D standard definition (SD) system, during the rental period from March 2016 were also included. Objective comparisons between the systems were made for newly diagnosed Knosp grade 0 to 3 pituitary adenomas. Surgical procedures were divided into nasal, sphenoidal, and intradural phases, and the surgical procedural time was compared for each phase. The time required for and accuracy of suturing the sellar floor dura was also evaluated. RESULTS: A total of 74 cases were treated with 3D/HD and/or 2D/4K, and 12 cases with 2D/SD. 3D/HD was advantageous in the nasal phase because of its intuitive depth perception. 2D/4K was advantageous in the intradural phase because of its superior image quality. Surgical time of the nasal phase with 3D/HD, and that of the intradural phase with 2D/4K, were significantly shorter than that with 2D/SD. The time required for and accuracy of sellar floor dural suturing showed a trend toward improving in the order of 2D/SD, 2D/4K, and 3D/HD. CONCLUSION: 3D/HD and 2D/4K endoscopy systems have different advantages, which are useful in distinct surgical phases. Understanding the characteristics of endoscopy systems is important for selecting the most appropriate system for distinct surgical situations.

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