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Endoscopic Endonasal Neurosurgery

What is Endoscopic Endonasal Approach?

Endoscopic endonasal approach (EEA) is a minimally invasive surgical technique that allows your surgeon to treat tissue damage and tumours near the spine or brain by utilising an endoscope placed through the nose and sinuses. An endoscope is a thin, long tube with a light and a tiny camera attached at the end that sends images to a computer screen for the surgeon to view the treatment area.

Endoscopic endonasal approach eliminates the need of making incisions in the skin or skull to access sections of your brain to remove abnormal tissue or tumours near the base of the skull or brain, and at the top of the spine. It enables your surgeon to treat many difficult-to-reach tumours and other conditions, which were once regarded as inoperable without disturbing the skull or face.

Indications for Endoscopic Endonasal Approach

Endoscopic endonasal approach may be recommended to treat a variety of conditions involving tumours and abnormal tissues in critical regions at the top of the spine or base of the skull, including:

  • Pituitary adenoma: A usually benign (noncancerous) growth or tumour on the pituitary gland.
  • Craniopharyngiomas: Noncancerous tumours that develop at the base of the brain close to the pituitary gland.
  • Rathke’s cleft cyst: Fluid-filled masses that develop above or within the pituitary gland.
  • Chondroma: A noncancerous tumour that develops in bones of the sinuses or bones in the skull base.
  • Meningioma of the skull base: Growth of tumour in the protective linings of the brain and spinal cord.
  • Nasopharyngeal carcinoma: The most common cancer that occurs in the nasopharynx (above the throat and behind the nose).
  • Chondrosarcoma: A cancerous tumour that can develop in the base of the skull.
  • Sinus tumour: A usually noncancerous growth in the nasal and sinus cavity.
  • Chordoma: A rare type of bone cancer that most often occurs in the bones of the spine or skull.
  • Acoustic neuroma: Noncancerous tumours that occur at the base of the skull.
  • Squamous cell carcinoma: A skin cell cancer that can affect the sinuses or skull base, or other areas of the brain.

Preparation for Endoscopic Endonasal Approach

Pre-surgery preparation for endoscopic endonasal approach may involve the following steps:

  • A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
  • Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise threaten the safety of the procedure.
  • You will be asked if you have allergies to medications, anaesthesia, or latex.
  • You should inform your doctor of any medications, vitamins, or supplements that you are taking.
  • You need to refrain from taking vitamin E, blood-thinners, pain relievers, or anti-inflammatories for 2 weeks prior to surgery.
  • You should refrain from smoking or alcohol for few weeks before surgery and several weeks after surgery.
  • You should not consume any solids or liquids at least 8 hours before surgery.
  • Arrange for someone to drive you home after surgery.
  • A written consent will be obtained from you after the pros and cons of the surgery has been explained in detail.

Procedure Involved in Endoscopic Endonasal Approach

In general, an endoscopic endonasal approach will involve the following steps:

  • You will be placed on the operating table in a way that gives your surgeon the best access to the portion of the area to be operated on.
  • An intravenous (IV) line is started in the arm to introduce fluids and medicine during the procedure.
  • The surgery may be performed under general anaesthesia or monitored anaesthesia (sedation) depending on your condition.
  • An image-guided device may be placed on your head which creates a 3D map on a computer screen. This map assists your surgeon in navigating through the nose.
  • A thin endoscopic tube attached to a lighted device and high-definition video camera at its end is inserted through one nostril and moved up to the back of the nasal cavity.
  • The endoscope relays images of the treatment area on a monitor, providing a magnified, high-resolution view of the tumour or abnormal tissue and surrounding significant structures.
  • Special miniature instruments are then inserted alongside the endoscope or through the other nostril to create a pathway to the brain, top of the spine, or skull base area.
  • A small portion of the nasal septum separating the two nostrils and the wall of the sphenoid sinus may be opened to access the treatment area for dissection and tumour removal.
  • Using unmatched illumination, optical resolution, and magnification of the surgical field provided by the endoscope and special instruments, your surgeon removes the damaged tissue and tumours from the treatment area.
  • Once suitable repair is achieved, the scope and instruments are withdrawn, and nasal packings are placed in your nose and sinuses to prevent bleeding and facilitate healing, which is usually removed in a week.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after endoscopic endonasal approach will involve the following steps:

  • You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions and monitor your vital signs as you recover.
  • You may need to stay in the hospital a day or two before being discharged home.
  • You may experience pain, inflammation, nasal congestion, and discomfort in the operated area. Medications are prescribed as needed to manage these.
  • Antibiotics are also prescribed to address the risk of surgery-related infection.
  • Avoid coughing, sneezing, blowing your nose, and straining during bowel movements for a few weeks after surgery.
  • Consult your doctor immediately if you experience continuous nasal drainage, excessive swallowing, nasal bleeding, high fever, frequent urination, or weight loss.
  • Refrain from smoking and alcohol for a specific period of time as it can hinder the healing process.
  • Refrain from strenuous activities and lifting anything heavier than 5 pounds until the first follow-up visit. These activities include housework, yard work, gardening, mowing, etc.
  • Low-intensity exercises such as gentle stretches and regular walking are recommended to improve strength and endurance. Gradual increase in activities over a period of time is recommended.
  • Refrain from driving until you are fully fit and receive your doctor’s consent.
  • A periodic follow-up appointment will be scheduled to monitor your progress.

Benefits of Endoscopic Endonasal Approach

Some of the key benefits of endoscopic endonasal approach include:

  • No external incisions and no visible scars
  • Minimal loss of blood
  • Minimal muscle trauma
  • Faster healing and recovery time
  • Shorter hospital stay
  • Less damage to the surrounding tissues
  • Less post-operative pain
  • Quick return to normal activities

Risks and Complications of Endoscopic Endonasal Approach

Endoscopic endonasal approach is a relatively safe surgical technique; however, as with any surgery, some risks and complications may occur, such as:

  • Infection
  • Bleeding
  • Hematoma (accumulation of blood in the wound site)
  • Damage to nerves, veins, arteries, and other structures
  • Allergic/anaesthetic reactions
  • Changes in nasal breathing
  • Nasal discharge/crusting
  • Inability to smell
  • Cerebrospinal fluid leak
  • Blood clots
  • Pneumonia
  • King's College London
  • Stanford University
  • University of Pittsburgh Medical Center
  • The Royal College of Surgeons of England