UPMC Video Rounds - Advances in EEA Techniques for Skull Base Surgery

Carl Snyderman, MD, co-director, Center for Cranial Base Surgery: 

With the evolution of endoscopic technologies, UPMC is now at the forefront of developing minimally invasive approaches to the skull base using endoscopic technology to go through natural orifices such as the nose to access the tumors that involve the ventral skull base.

The biggest challenge in doing surgery for patients with angiofibromas is the vascularity of the tumor. When there's excessive bleeding you can't see structures. There's a greater risk of injury to cranial nerves or major arteries and so this has been the limiting factor, especially as we start to use endoscopic techniques for the removal of even very large angiofibromas.

For tumors that are situated in the petrous apex behind the carotid artery, we are limited using an endonasal approach. We developed what's called the contralateral transmaxillary approach in which we use a standard, Caldwell-Luc approach going through the mouth on the contralateral side. By creating a window there, we now establish a corridor that crosses the back of the nose and reaches the contralateral petrous apex. This puts us in line with the course of the trajectory of the internal carotid artery so now we can remove tumors from that area safely without the need for further mobilization or manipulation of the carotid artery.

One of the work horses of open cranial base surgery has been the pericranial flap. So we wanted to devise a new way of introducing that flap without the need for a craniotomy. And so we developed a minimally invasive approach called the extracranial pericranial flap, and instead of doing a craniotomy, we created a little window in the bone at the level of the nasion and now we can introduce this flap through that window below the frontal sinus, below the plain of the skull base and we have a very large vascularized flap that can be used to reconstruct really any size defect.

We conducted a clinical trial of a fluorescence endoscope which allows us to assess the vascularity of tumors and flaps and better differentiate tumor tissues from normal tissues. In the future we will continue to develop new imaging technologies that will allow us to see things that we can't see with the naked eye.

Learn more about the Department of Otolaryngology at UPMC.