Comprehensive review on rhino-neurosurgery

Abstract

In the past 2 decades, an innovative and active field of surgical collaboration has been evolved and established combining the expertise of neurosurgery and rhinosurgery in the endonasal treatment of different lesions affecting the anterior skull base together with the adjacent intranasal and intradural areas. Important prerequisites for this development were improvements of technical devices, definitions of transnasal surgical corridors, and approvements in endonasal reconstructions, e.g. by use of pedicled nasal mucosal flaps. Due to these improvements, the rate of perioperative infectious complications remained acceptable. Interdisciplinary surgical teams (4-hands-2-minds) have been established constituting specialized centers of "rhino-neurosurgery". With growing expertise of these groups, it could be shown that oncological results and perioperative complications were comparable to traditional surgery while at the same time the patients' morbidity could be reduced. The present review encompasses the recent literature focusing on the development, technical details, results, and complications of "rhino-neurosurgery".

Keywords: endoscopic endonasal sinus surgery; rhino-neurosurgery; skull base surgery.

Table 1. Timetable – interdisciplinary milestones regarding the development of endoscopic rhino-neurosurgical interventions [3, 6-9, 81, 298, 316, 331, 349, 383, 393, 427, 548, 552, 684, 726, 745-51]

Table 2. Corridors, approaches, and target structures of rhino-neurosurgical interventions according to Schwartz et al. [30, 67]

Table 3. Classification of endoscopic endonasal skull base procedures, accesses of the median-sagittal level: modules and corridors with their parameters and the most frequent basic pathological processes according to Kassam et al. [55, 68]

Table 4. Classification of endoscopic endonasal skull base procedures, accesses of the paramedian level: modules and corridors with their parameters and the most frequent basic pathological processes according to Kassam et al. [68] (nerve of the pterygoid canal = Vidian nerve)

Table 5. Often used indication (examples) for endonasal endoscopic skull base surgery according to the current literature [extended according to 30, 41, 72, 131, 279, 752]

Table 6. Parts of the course of the internal carotid artery

Table 7. Examples of current anatomical classification systems relevant for the field of rhino-neurosurgery

Table 8. Training program with gradually increased difficulty levels of endonasal rhinological and rhino-neurosurgical interventions (simplified and summarized based on [36, 41, 55, 68, 354, 376])

Table 9. Endoscopic transnasal access to the cavernous sinus [449]

Table 10. Subtypes of the transpterygoid approach according to Kasemsiri et al. [71]

Table 11. Approaches to the pterygopalatine fossa, the infratemporal fossa, or the parapharyngeal space according to Taylor et al. [455]

Table 12. Subtypes of nasopharyngeal endoscopic resection (NER) according to Castelnuovo et al. [126, 143]

Figure 1. Example of endoscopic endonasal resection of a chordoma via a transclival approach. a, b The 36-year-old female patient presented with sudden headaches and paresis of the oculomotor nerve. Imaging revealed a large hemorrhagic, contrast enhancing petroclival tumor with extension in suprasellar direction and into the right cerebellopontine angle. The tumor led to a significant compression of the mesencephalon and pons. During preparation for surgery, the patient developed ophthalmoplegia on the right side and a high-grade hemiparesis on the left. Because of the progredient neurological deficits, surgery was performed as an emergency intervention. c Resection of the clivus with the high-speed drill with presentation of the clival internal carotid artery and the sellar dura. In order to create enough space for microsurgical preparation, the roof of the clival carotid artery was removed on both sides and the sella was completely decompressed. d Resection of the posterior clinoid process in order to reach cranial tumor parts. e Tumor resection with the curette. f Bimanual sharp separation of the tumor capsula from the superior cerebellar artery. g Inspection of the cerebellopontine angle with the 45° optic after removal of the tumor shows the trochlear and trigeminal nerves. h Inspection in cranial direction with the 45° optic reveals the basilar tip with the efferent arteries as well as the oculomotor nerve on both sides. i Presentation of the transclival approach which was used for resection of the large chordoma. j A fat graft is glued into the clival skull base defect. k Reconstruction of the skull base with a nasoseptal flap. l The postoperative MRI shows complete tumor resection and the nasoseptal flap well supplied with blood (arrows). The neurological deficits were completely regredient soon after surgery.

Figure 2. Posterior wall of the sphenoid sinus with the typical anatomical landmarks

Figure 3. Endoscopic view with 30° optic on the suprasellar neuro-vascular structures (arrow: tractus hypophyseus superior)

Figure 4. Endoscopic view with 45° optic on the suprasellar neuro-vascular structures (arrow: tractus hypophyseus superior)

Figure 5. Endoscopic view with 45° optic into the interpeduncular cistern

Figure 6. Endoscopic view with 30° optic on the course of the Vidian nerve of the right side (arrows)

Figure 7. Arrangement of devices and personnel in an operation theater for a rhino-neurosurgical intervention (4-hands technique) [111]

Figure 8. View into the 3^rd ventricle with a 45° optic after resection of a craniopharyngioma