Surgeons at the Center for Cranial Base Surgery at Penn Medicine are performing innovative, minimally invasive endoscopic procedures for the treatment of complex skull-base disorders, including craniofacial malignancies and tumors, sinonasal cancers extending to brain, benign neural lesions (i.e., meningiomas, craniopharyngiomas, clival chordomas) and such rare cancers as esthesioneuroblastoma. The cranial base is adjacent to the brain and paranasal sinuses, and can be generally described as the nexus for a dense concentration of neural, vascular and skeletal tissue. The contiguous and interconnected nature of these organs in relation to the size and potential invasiveness of lesions originating in the skull base offer a particularly challenging environment for surgery.

To address the complexities of the region, the surgical management of skull-base disorders at Penn Medicine is based on a comprehensive, integrated and multidisciplinary approach. Treatment combines minimally invasive endoscopic technology with advanced neuroradiologic mapping, and can maximize the identification and resection of diseased tissue while reducing the intraoperative and postoperative effects of surgery. Surgery is performed through the natural orifices of the face whenever possible to minimize the size of incisions and reduce their cosmetic impact. The combination of these techniques often result in less blood loss, faster recovery and superior outcomes for patients.

Neuronavigation

Advanced neurodiagnostic technologies are employed intraoperatively to enhance accuracy during surgery. [1] Neuroradiologic mapping produces highly precise clinical imaging of advanced tumors within the central and peripheral nervous system; interventional angiography defines critical vascular structures and decreases blood loss during certain procedures; cranial nerve monitoring during surgery identifies and preserves vision, hearing, balance, and facial expressions as well as speech and swallowing; and intraoperative computer-assisted navigation identifies the precise location of tumors in relation to surrounding vital tissues.

Case Study

Mr. L, a 46-year-old man, was referred to Penn Medicine by his primary care physician with a history of nasal obstruction and intermittent epistaxis. His examination revealed a polypoid mass extending bilaterally along the fovea ethmoidalis, with erosion of a portion of the upper nasal septum. Mr. L had a cranial CT scan that revealed a heterogeneous solid mass spanning the anterior cranial base, with involvement of the bilateral nasal cavity and loss of bony continuity along the anterior cranial base (Figure 1).

Image of sinonasal undifferentiated carcinoma spanning the anterior cranial base of the skull
Figure 1. Sinonasal undifferentiated carcinoma spanning the anterior cranial base, with involvement of the bilateral nasal cavity and loss of bony continuity along the anterior cranial base.

Subsequently, a stereotactic MRI was performed and fused with the findings of the CT scan to create a three-dimensional stereotactic map of the tumor and its surroundings. This confirmed intracranial involvement of the tumor. A biopsy was performed, confirming the diagnosis of sinonasal undifferentiated carcinoma (SNUC).

Mr. L was admitted to Penn Medicine, where a team of neurosurgeons and otorhinolaryngologists with the Center for Cranial Base Surgery performed a minimally invasive procedure using 4-hand surgical techniques. After clearing the tumor from the sinonasal cavity, an endoscope was first advanced trans-nasally to the suprasellar region to visualize and identify the optic nerves and chiasm and further map the lesion.

Prior to the resection of the tumor, a vascularized nasoseptal tissue flap consisting of the patient’s own mucus membrane was harvested and placed into the nasopharynx. The tumor was debulked using a micro Cavitron ultrasonic surgical aspirator (CUSA), bipolar diathermy and endoscopic instruments. The portion of the tumor adherent to the optic nerves and chiasm was dissected away with microscissors. The previously harvested tissue flap was then retrieved to close and seal the surgical site, and further sealed using biologic tissue adhesives.

Following surgery, Mr. L was closely monitored in the neurointensive unit for three days, and then discharged to home. He recovered well, with no recurrence of his previous symptoms and no post-surgical neurological effects, and resumed his normal activities several weeks later.

Access

Department of Otorhinolaryngology - Head and Neck Surgery
The Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia, PA 19104

Pennsylvania Hospital
811 Spruce Street
Philadelphia, PA 19107

Department of Neurosurgery
Hospital of the University of Pennsylvania
3 Silverstein
3400 Spruce Street
Philadelphia, PA 19104

Pennsylvania Hospital
4th floor
330 South 9th Street
Philadelphia, PA 19107

Published on: November 30, 2017

References

1. Periera VM, Vargas, MI, Marcos A, et al. World J Radiol 2013;5:386–397.

About Penn Otorhinolaryngology - Head and Neck Surgery

The management of skull-base disorders at the Center for Cranial Base Surgery at Penn Medicine involves otorhinolaryngologists and neurosurgeons and specialists trained in facial plastic and reconstructive surgery, radiation oncology, oncology and interventional neuroradiology, as well as specialists from the Center for Head and Neck Cancer and the extensive network of support and rehabilitation services available at Penn.

Penn Faculty Team

M. Sean Grady, MD

Chairman, Department of Neurosurgery

Charles Harrison Frazier Professor of Neurosurgery

Professor of Otorhinolaryngology: Head and Neck Surgery

Jason G. Newman, MD, FACS

Co-Director, Cranial Base Center

Director, Head & Neck Surgery, Pennsylvania Hospital

Associate Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania and the Pennsylvania Hospital

James Palmer, MD

Co-Director, Cranial Base Center

Director, Division of Rhinology

Professor of Neurosurgery

Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

Nithin D. Adappa, MD

Surgical Director, Penn AERD Center

Assistant Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

Michelle Alonso-Basanta, MD, PhD

Helene Blum Assistant Professor

Steven Brem, MD

Co-Director, Brain Tumor Center

Director of Neurosurgical Oncology

Professor of Neurosurgery at the Hospital of the University of Pennsylvania

Douglas Bigelow, MD

Co-Director, Center for Cranial Base Surgery

Director, Division of Otology/Neurotology

Associate Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

Jason A. Brant, MD

Assistant Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

Ara A. Chalian, MD

Director, Facial Plastic Reconstruction

Director, Microvascular Lab

Patient Safety Officer

Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

David W. Kennedy, MD

Rhinology Professor

James D. Kolker, MD

Chief, Section of Radiation Oncology, Pennsylvania Hospital

Medical Director, CyberKnife

Clinical Associate Professor of Radiation Oncology

Kim O. Learned, MD

Assistant Professor of Clinical Radiology

John Y.K. Lee, MD, MSCE

Medical Director, Gamma Knife Center

Associate Professor of Neurosurgery at the Pennsylvania Hospital

Associate Professor of Otorhinolaryngology: Head and Neck Surgery

Laurie A. Loevner, MD

Division Chief, Neuroradiology

Professor of Neurosurgery

Professor of Ophthalmology

Professor of Radiology at the Hospital of the University of Pennsylvania

John N. Lukens, MD

Assistant Professor of Radiation Oncology at the Hospital of the University of Pennsylvania

Robert Lustig, MD

Director, Network Development Program

Professor of Clinical Radiation Oncology

Bert W. O'Malley, Jr., MD

Associate Vice President, Physician Network Development

Chair, Department of Otorhinolaryngology - Head and Neck Surgery

Co-Director, Head and Neck Cancer Center

Gabriel Tucker Professor of Otorhinolaryngology: Head and Neck Surgery

Professor of Otorhinolaryngology in Neurosurgery

Professor of Radiation Oncology

Christopher H. Rassekh, MD

Associate Professor of Clinical Otorhinolaryngology: Head and Neck Surgery

Michael J. Ruckenstein, MD, MSc, FACS

Director, Implantable Hearing Devices Program

Director, Residency Training and Education

Vice Chairman, Department of Otolaryngology

Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

Gregory S. Weinstein, MD, FACS

Co-Director, Center for Head and Neck Cancer

Director, Head and Neck Oncology Fellowship

Director, Head and Neck Surgery Division and Head and Neck Surgery Clinic

Vice Chairman, Department of Otorhinolaryngology: Head and Neck Surgery

Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

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