A first exploration of the economic consequences of an autonomous surgical robot for lateral skull base surgery: an early health technology assessment.

OBJECTIVES: Lateral skull base procedures, such as translabyrinthine approach (TLA), are challenging. An autonomous surgical robot might be a solution to these challenges. Our aim is to explore in an early phase the economic consequences of an autonomous surgical robot compared with conventional TLA. METHODS: An early decision analytic model was constructed in order to perform a step-wise threshold analyses and a sensitivity analysis to analyze the impact of the several factors on the incremental costs. RESULTS: Using surgical robot results in incremental costs - EUR 5,562 per procedure - compared to conventional TLA. These costs are most reduced by higher number of procedures, followed by lower price of the robot, saved operation time, and reduced risk of complication, respectively. CONCLUSIONS: The incremental costs of using an autonomous surgical robot can be decreased by choosing applications with a high turnover rate, a long operation time, and a high complication rate.

Endocrinological outcomes after transcranial resection of tuberculum sellae meningiomas: a systematic review and meta-analysis.

Tuberculum sellae meningiomas (TSMs) arise from the anterior skull base. Endocrine status after TSM resection is an important determinant of quality of life. We sought to better characterize the risk of postoperative endocrinopathy for patients with TSM undergoing open transcranial approach (TCA) microsurgical resection. A systematic review was conducted following MOOSE and PRISMA guidelines. Results were screened against predefined criteria, which included studies evaluating endocrinopathy rates after open transcranial microsurgery for TSM. Outcome incidence was calculated using random-effect meta-analysis of proportions. Eight studies met the inclusion criteria, comprising 406 patients. The average age of the cohort was 52.2 years, and a majority (70%) of the patients were female. The pooled incidence of postoperative transient diabetes insipidus (DI) was 7.5% (95% CI 2.9-12%; p = 0.001; I2 = 75.9%) and permanent DI was 1.6% (95% CI 0.3-2.7%; p = 0.01; I2 = 0%). The pooled rate of postoperative hypopituitarism was 3.6% (95% CI 1.6-5.7%; p < 0.001; I2 = 22.2%), while the incidence of hyperprolactinemia was 1.3% (95% CI 0.1 = 2.6%; p = 0.036; I2 = 8.74%). The incidence of SIADH was 4% in one study but was not included in the meta-analysis. Endocrinopathy after TSM microsurgical resection is rare, but the available studies' poor quality of evidence and inconsistent methodology may reflect that it is underreported in the literature. Nevertheless, clinicians should consider the risk of hormonal impairment and counsel their patients accordingly when selecting a TCA for these lesions.

Hydroxyapatite cement cranioplasty for reconstruction of translabyrinthine approach: aesthetic results, long-term satisfaction, quality of life, and complications.

BACKGROUND: Translabyrinthine approaches (TLAs) for resection of skull base neoplasms are complex with variable reconstruction techniques. Fat grafts in conjunction with hydroxyapatite bone cement techniques have seldom been described in terms of possible superiority to other skull base reconstruction techniques. We sought to determine the impact of this skull base reconstruction technique on clinical outcomes and patient's satisfaction. METHOD: We performed a retrospective analysis of all patients who underwent translabyrinthine approaches for resection of CPA lesions over a 5-year period. Both post-op objective and subjective markers of reconstruction, as well as postoperative complications, were collected and analyzed. RESULTS: Sixty-nine patients were included, 34 underwent reconstruction with hydroxyapatite and fat (rHAC) and 35 with fat alone (rF). rHAC was associated with fewer cranial wound superficial infection/dehiscence (0% vs 14.3%; p = 0.029) and shorter length of stay (mean ± standard deviation) (6.9 ± 7.4 vs 4.4 ± 3.7 days, p = 0.008). Postoperative subjective characterization of rHAC demonstrated improved satisfaction scores (1.38 ± 0.5 vs 1.83 ± 1; p = 0.049) and fewer reports of post-operative irregularities (11.5% vs 37.5%; p = 0.017). CONCLUSION: The use of hydroxyapatite for cranial reconstruction after translabyrinthine approaches has improved patient satisfaction and decreased cranial defects in our small series. Postoperative complications are consistent with other described methods, but with shorter hospital stay, decreased risk of superficial wound dehiscence/infection, and a perceived superiority in preventing percutaneous post-op CSF leaks.

Preservation of nasal turbinates in endoscopic, anterior skull base surgery-yes, we can!

OBJECTIVE: To evaluate the frequency, type and indications of nasal turbinate (NT) resection during endoscopic, anterior skull base surgery and to analyze factors that may have an impact on the need of NT removal. METHODS: In this retrospective cohort study, 306 subjects (150 males and 156 females, mean age 55.4 ± 15.3 years) who underwent multidisciplinary, transnasal, endoscopic tumor surgery of the anterior skull base using 4-handed techniques between 2011 and 2019 at the Department of Otorhinolaryngology, Medical University of Graz, were included. RESULTS: In the majority of interventions (n = 281/306; 91.8%), all NT were preserved. Significant factors influencing the need of NT resections turned out to be type of endoscopic approach (p < 0.001; V = 0.304), sagittal (p = 0.003; d = 0.481) and transversal (p = 0.017; d = 0.533) tumor diameter, tumor type (p < 0.001; V = 0.355) and tumor location (p < 0.001; V = 0.324). CONCLUSIONS: NT can be preserved in the majority of patients undergoing tumor resection in anterior, transnasal, skullbase surgery and routine resection of NT should be avoided. Variables that have an impact on the need of NT resections are types of endoscopic approaches, sagittal and transversal tumor extension and tumor type. These factors should be considered in planning of surgery and preoperative information of patients.

Combined biportal unilateral endoscopic endonasal and endoscopic anterior transmaxillary approach for resection of lesions involving the infratemporal fossa.

BACKGROUND: Approaching tumors involving the infratemporal fossa (ITF) is technically challenging due to the complex relationships between several neurovascular structures and the deep-seated location of these lesions. METHODS: The authors describe in detail a minimally invasive approach to the ITF, consisting on a single-nostril endoscopic endonasal transmaxillary approach aided by an anterior transmaxillary port (EEA-ATMa). Anatomical landmarks and surgical tenets of this approach are highlighted and reviewed with the goal to guarantee successful tumor resection and avoid operative complications. CONCLUSION: The EEA-ATMa is technically feasible and offers excellent surgical exposure to the anterior and lateral aspect of ITF, without the need of transecting the Vidian nerve or performing a wide septectomy.

[Accreditation and certification of skull base centres in Germany by the German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB). German version]. / Akkreditieren und Zertifizieren von Schädelbasiszentren in Deutschland durch die Gesellschaft für Schädelbasischirurgie (GSB).

The German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB) has developed a protocol for the certification of GSB skull base centres. The development of such a protocol has led to numerous open and sometimes controversial discussions among the GSB members. The various critical discussion points will be reviewed and the ensuing results, which will then be included in the accreditation protocol, presented. The current GSB accreditation protocol will be presented and explained in an international comparison.

Accreditation and certification of Skull Base Centres in Germany by the Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB).

The German Society for Skull Base Surgery (Gesellschaft für Schädelbasischirurgie, GSB) has developed a protocol for the certification of GSB skull base centres. The development of such a protocol has led to numerous open and sometimes controversial discussions among the GSB members. The various critical discussion points will be reviewed and the ensuing results, which will then be included in the accreditation protocol, presented. The current GSB accreditation protocol will be presented and explained in an international comparison.

Optimal surgical approaches and treatment outcomes in patients with jugular foramen schwannomas: a single institution series of 31 cases and a literature review.

Complete resection of jugular foramen schwannomas (JFSs) with minimal cranial nerve complications remains difficult even for skilled neurosurgeons. Between November 2011 and November 2017, 31 consecutive patients diagnosed with JFSs underwent a single-stage operation performed by the same neurosurgeon. We retrospectively analyzed clinical characteristics, surgical approaches, treatment outcomes, and follow-up data for these patients. JFSs were classified according to the Samii classification system. A retrosigmoid approach was used to resect type A tumors, while a suboccipital transjugular process (STJP) approach was used to resect type B tumors. Notably, the present study is the first to report the use of a paracondylar-lateral cervical (PCLC) approach for the treatment of type C and D tumors. Type A-D tumors were observed in seven, four, four, and 16 patients, respectively. Gross-total resection was achieved in 29 patients (93.5%). There were no cases of intracranial hematoma, re-operation, tracheotomy, or death. Adjunctive gamma knife treatment was used to manage residual tumors in two patients. Neurological deficits relieved in half of patients at the last follow-up. By reviewing the studies published on PubMed, the approaches gradually be more conservative, rather than widely expose the skull base. Nonetheless, endoscope and stereotactic radiosurgery plays an important role in the management of JFSs. Both tumor removal and neurological function retention can be obtained by choosing individual treatment.

Peri-Incisional Botulinum Toxin Therapy for Treatment of Intractable Head Pain After Lateral Skull Base Surgery: A Case Series.

OBJECTIVE: The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery. BACKGROUND: Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes. METHODS: In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months. RESULTS: All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value. CONCLUSIONS: Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.

Chordomas: Histopathological Study in View of Anatomical Location.

BACKGROUND: Chordomas are aggressive bone tumors that have a predilection for the axial skeleton including the skull base and spinal/sacral bones. However, the histopathological and clinical differences between skull base chordoma (SBC) and sacral/spinal chordoma (SC) are unclear as previous studies have been focused on patient prognosis and treatment outcome. This study aimed to evaluate the clinicopathologic features and prognosis of chordoma according to its location. METHODS: Patients with chordomas were enrolled, and the histopathologic features were compared according to the tumor location. RESULTS: A total of 52 patients were enrolled. SBCs had more abundant chondroid matrix and diffuse growth pattern, while SCs had non-chondroid, myxoid matrix and a lobulating pattern, typical of chordoma. Old age and residual tumors were risk factors for shorter overall survival in SBCs. The chondroid matrix was an independent risk factor for shorter disease-free survival in the overall population. CONCLUSION: Chordomas have different histopathologic features depending on the anatomical location.

Neuroglial ectopia of the vestibular nerve masquerading as a vestibular schwannoma: A case report.

Neuroglial ectopia is a rare entity of undetermined clinical significance. Here, we report a unique case of neuroglial ectopia of the vestibular nerve. A 27-year-old pharmacy student with a previous radiological diagnosis of vestibular schwannoma presented to our clinic for surgical evaluation. Magnetic resonance imaging (MRI) of the brain revealed a 17-mm T1 hypo- to isointense, T2 iso- to hyperintense, poorly enhancing left cerebellopontine angle mass extending into the left internal auditory canal compatible by imaging with a vestibular schwannoma. The lesion was resected under MRI guidance. The frozen specimen came back as a benign hypocellular lesion. Histological assessment revealed a peripheral nerve engulfed by glial fibrillary acidic protein-positive, S-100-negative cells, suggestive of neuroglial ectopia. There was no evidence of schwannoma. The main concerns were benign neoplasm with potential for progression or sampling artifact. The patient had an uncomplicated hospital course. This case report demonstrates an unusual case of neuroglial ectopia of the vestibular nerve. The differential diagnoses for a poorly enhancing cerebellopontine angle mass should include neuroglial ectopia.

[Paracondylar-lateral cervical approach for resection of jugular foramen schwannomas: a retrospective analysis of 15 cases].

Objective: To explore the effects of paracondylar-lateral cervical approach for resection of the jugular foramen schwannoma(JFS). Methods: A total of 15 patients with JFS operated via the paracondylar-lateral cervical approach between December 2011 and March 2016 at Department of Neurosurgery in Xiangya Hospital of Central South University were retrospectively analyzed. There were 7 males and 8 females, aging from 22 to 77 years with a mean age of (41.9±15.8) years.There were 12 patients who accepted primary surgery, 3 patients who accepted secondary surgery. There were 10 patients with tinnitus or hearing loss, 8 patients with dysphagia, 9 patients with hoarseness, 7 patients with tongue hemiparesis, 8 patients with ataxia, 1 patient with Pyramidal signs, 2 patients with facial hypesthesia or pain, 1 patient with facial paresis. According to Samii JFS grading system, 2 patients were type B, 4 were type C and 9 were type D. All patients were followed-up through outpatient and telephone by MRI in 3, 9, 12 months postoperation. Results: Gross total removal of tumors were achieved in 14 patients and subtotal removal in 1 patient. Two patients had new hoarseness, 2 had new dysphagia and 3 had more serious dysphagia, 1 patient had more serious facial paresis after the operation. There were 2 patients with intracranial infection, 2 with pneumonia, 1 with subcutaneous effusion, 1 with cerebrospinal fluid rhinorrhea, 5 with gastric intubation during perioperative period. There were no death, intracranial hematoma and decreased hearing patients. All patients were followed up, the follow-up time were 3 to 33 months with a mean of (26.9±11.2) months. Till to the latest follow up, dysphagia improved in 2 cases, hoarseness and tongue hemiparesis improved in 3 cases, hearing loss and tinnitus improved in 9 cases, balance function improved in 7 cases, facial hypesthesia and pain improved in 2 cases, pyramidal signs disappeared in 1 case, facial nerve function improved to normal in 1 case. There was no recurrence and progressed case. Conclusion: Paracondylar-lateral cervical approach is an alternative approach for both intracranial and extracranial JFS.

Clival Chordoma: Case Report and Review of Recent Developments in Surgical and Adjuvant Treatments.

Chordomas are rare tumors that can develop anywhere along the craniospinal axis. These tumors present challenges with respect to diagnosis and treatment due to a high rate of recurrence, even after multiple surgeries, and the propensity to involve any region within the craniospinal axis. New developments in radiation therapy have improved recurrence-free survival in patients with chordomas. Different regimens of chemotherapy and molecularly-targeted therapies, as adjuvants to surgery, have been described in individual case reports and case series. The purpose of this paper is to describe a case of clival chordoma and review recent developments in diagnostic and therapeutic options. A 77-year-old female was referred because of diplopia and progressively worsening headaches. Head imaging revealed a large expansile and erosive mass in the skull base. The patient underwent a successful endoscopic endonasal trans-sphenoidal resection of the mass, with biopsy confirming the diagnosis of chordoma. Postoperatively, the patient experienced an improvement in neurological symptoms. Chordomas can present a diagnostic challenge due to the rare occurrence and a tendency to involve any region within the craniospinal axis.

Skull Base Tumors and Tumor-Like Lesions: A Pictorial Review.

A number of tumors and tumor-like non-neoplastic lesions with different cell types on histology occur in the skull base. A wide variety in disease and lesion appearance often complicates the process of radiological diagnosis. The main role of radiographic imaging is the detection and characterization of skull base lesions, with evaluation of the extent of invasion or preservation of adjacent critical organs. Evaluation of the skull base anatomy and surgical planning by using image guidance are also important for surgeons. Computed tomography (CT) and magnetic resonance (MR) imaging are the preferred modalities for the evaluation of skull base lesions. CT and MR are used for lesion detection, tissue characterization and assessment of neurovascular and bone involvement by the lesions. Both modalities provide useful information, one sometimes of greater value than the other. T1-weighted MR imaging is useful in detecting skull base lesions, typically surrounded by abundant fatty bone marrow. T2-weighted MR imaging is generally useful for tumor tissue characterization. CT surpasses MR imaging in evaluating intratumoral calcification and bone destruction or hyperostosis. To date, imaging features have been well-reported in individual skull base tumors; however, correct diagnosis by imaging alone still presents a challenge. Knowledge of clinical issues and awareness of variants of skull base tumors are of help in making a diagnosis. The purpose of this article is to review pertinent clinical issues, typical imaging appearances and certain imaging variations of common skull base lesions.

Sphenoid plasmacytoma as initial presentation of multiple myeloma-case report.

Plasmacytoma is a rare plasma cell neoplasm. Whether solitary or associated with multiple myeloma (MM), it rarely involves the skull base, particularly the sphenoid bone. We present a unique case of sphenoid bone plasmacytoma secondary to MM, highlighting diagnostic and therapeutic challenges. A 56-year-old female presented with headaches, vomiting, epistaxis, and cranial nerve deficits. Cerebral imaging revealed a 65-mm tumor infiltrating the sphenoid bone and adjacent structures. Subtotal resection was performed using an endoscopic nasal approach. Histopathology revealed plasmacytoma, and diagnostic workup confirmed MM. By the end of biological exploration, relapse of the sphenoid plasmacytoma was observed, and the patient was successfully treated with radiotherapy, immunochemotherapy, and autologous stem cell transplantation. After 18-month follow-up, sustained complete remission was confirmed. Although rare, the diagnosis of plasmacytoma should be considered in cases of skull base tumors. This localization is highly predictive of MM, warranting comprehensive investigations to initiate prompt and adequate management.

A Multidisciplinary Skull Base Board for Tumour and Non-Tumour Diseases: Initial Experiences.

The skull base is the area where various cancerous and non-cancerous diseases occur and represents the intersection of several medical fields. The key is an integrated treatment by specialists of multiple disciplines. We prospectively analysed patients with a skull base disease between August 2022 and 2023 and presented to the Multidisciplinary Skull Base Board (MDT-SB), which takes place once a month hybridly (in-person and remotely). Thirty-nine patients (median age of 58.2 years) were included, of which twelve (30.8%) had a benign tumour, twelve (30.8%) had a malignant tumour, five had an infection (12.8%), and ten (25.6%) had other diseases. For each patient, at least two otorhinolaryngologists, a neurosurgeon, and a neuroradiologist, as well as an infectious disease specialist, a paediatrician, an oculoplastic surgeon, a maxillofacial surgeon, and a pathologist were involved in 10%, 8%, 8%, 3%, and 3% of cases, respectively. In fifteen patients (38%), the MDT-SB suggested surgical treatment; in fourteen (36%), radiological follow-ups; in five (13%), non-surgical treatments; in two, conservative treatments (5%); in two (5%), surgical and conservative treatments; and in one (3%), a biopsy. Non-cancerous and cancerous diseases of the skull base in adults and children should be presented to the MDT-SB, which consists of at least an otolaryngologist, a neurosurgeon, and a neuroradiologist.

Poorly differentiated sinonasal neuroendocrine carcinoma with skull base invasion: A case report.

Background: Sinonasal neuroendocrine carcinoma is a rare head and neck tumor that represents only 5% of sinonasal neoplasms. This lesion has a high risk of invasion to adjacent structures such as the orbit, skull base, and soft tissues, with symptoms usually being nonspecific. Most cases are diagnosed in late stages, decreasing overall survival without treatment. To date, there is no consensus on management given its low prevalence; however, it has been shown that multimodal therapy, with the correct surgical approach as the mainstay, offers a better disease-free prognosis. Case Description: A 46-year-old woman presented with a 1 year history of nasal symptoms, characterized by obstruction and epistaxis. Imaging studies showed an extra-axial mass causing skull base erosion and displacement of the right fronto-orbital region, without invasion of brain parenchyma or meninges. A biopsy was performed and an unresectable poorly differentiated sinonasal neuroendocrine carcinoma was diagnosed. Treatment with radio and chemotherapy was initiated and, as the tumoral volume decreased, she was referred for neurosurgical intervention; an endonasal endoscopic approach was performed. Gross total resection was achieved and the patient was discharged without postoperative complications and no residual lesion on imaging. Conclusion: We describe the evolution of a rare advanced-stage neoplasm. It highlights that despite receiving an initial diagnosis of an unresectable mass, multimodal therapy, and an adequate surgical approach deemed the entire lesion to be resected. Despite the favorable clinical evolution, the follow-up of neuroendocrine carcinoma is prioritized as a neoplasm with a high rate of recurrence and metastasis.

Pterygopalatine-Infratemporal Fossa Hydatid Cyst Resembling Cystic Tumor.

Hydatid cyst is an endemic disease in Mediterranean and Middle Eastern countries, Eastern European countries, East Africa, China, New Zealand, Australia. We aimed to present this educational case, which is endemic in our country and seen in a very rare localization, with the combined surgical approach, within the literature.

Clival and Paraclival Lesions: A Pictorial Review.

The clivus is a midline anatomical structure in the central skull base. It is affected by a wide range of non-neoplastic, benign and malignant pathologies, some of which typically affect the clivus because of its strategic location and embryological origins. Clival lesions may often be asymptomatic with occasional complaints like headache or cranial neuropathy in few. Cross-sectional imaging techniques, namely, computed tomographic scan and magnetic resonance imaging, thus, play a key role in approximating to the final diagnosis and estimating the disease extent. In this article, we highlight the important imaging features of various clival and paraclival pathologies to facilitate effective diagnosis, therapeutic planning, and management.

Quality of Life in Patients With Benign Lateral Skull Base Neoplasms Following Infratemporal Fossa Approaches.

Objectives: Infratemporal fossa approaches (IFAs) allow the total resection of certain lateral skull base neoplasms. To date, no studies have explored the change of patient-reported quality of life (QoL) after total resection of benign lateral skull base neoplasms through IFA. The present study aimed to give a comprehensive understanding of QoL among patients after IFA through general and disease-specific QoL questionnaires. Methods: Forty-seven patients with benign lateral skull base neoplasms were enrolled. The Short Form 36 (SF-36), World Health Organization Quality of Life-BREF (WHOQOL-BREF), and the University of Washington Head and Neck Quality of Life (UW-QOL) were chosen as tools to assess QoL before and after surgeries through IFA. Results: Patients had significantly lower scores in appearance, chewing, and speech after surgeries through IFA. However, change in health from SF-36 and physical health from WHOQOL-BREF scored higher after surgery. In multivariate linear regression analysis, age, gender, mood, speech, appearance, swallowing, and chewing contributed independently to general QoL. Conclusion: Patients were shown to benefit with regard to overall QoL after gross tumor resection from IFA, despite the impact of appearance, speech, and chewing. Function preservation and restoration are critical since their correlation with postoperative QoL.