The skull base is a complex area that interfaces between the brain above and the sinuses, eyes, and portions of the face below. A wide variety of problems arise here. Due to complex anatomy and limited access, treatment of these problems can be challenging and requires advanced expertise. Comprehensive management frequently entails extensive collaboration with the neurosurgical service as well as potentially with ophthalmologists, radiation oncologists and medical oncologists.
Complete evaluation typically requires consultations with these services along with nasal endoscopy and diagnostic imaging (MRI and/or CT).
Traditionally, surgery for these disorders required open surgeries that approached the lesion from above (craniotomy – through the top of the skul), below (transfacial – through incisions in the face) or both. These often require large incisions and cuts in the bones of the face and skull in order to safely and adequately access the problem. Advances in technology and surgical technique have enabled more minimally invasive endoscopic approaches through the nostrils (transnasal approach) that may improve outcomes and decrease complications
Cerebrospinal Fluid (CSF) leak & Encephalocele
Leakage of the spinal fluid that surrounds the brain and spine can occur when there is a communication or hole in the skull base. Occasionally, non-functional brain tissue called an encephalocele will be pushed through this hole in the skull base as well. The fluid will drip through the nose and can often time present as a one-sided "runny-nose" or sometimes with headaches. Serious complications can develop if this problem is left untreated with the development of a potentially life-threatening infection called meningitis. Treatment involves surgically removing the encephalocele (if present) and repairing the hole with a patch to restore the normal separation of the nose and brain. These surgeries can almost always be done endoscopically through the nose without any visible incisions.
Sinus and Nasal Tumors
A wide variety of tumor types can occur in the nose and sinuses. Often these are benign (non-cancerous) and can be relatively easily removed using techniques similar to sinus surgery. The key is complete removal of the tumor to prevent them from coming back as well as turning into cancer later on. Occasionally, malignant (cancerous) tumors will occur the nose. The treatment varies on the type of tumor, but typically involves a combination of surgery, radiation and possibly chemotherapy. Certain cancers can be removed by minimally invasive transnasal endoscopic techniques, though more advanced disease may require the addition of open surgical approaches.
Tumors can develop in the space behind the nose called the nasopharynx. Some of these tumors can be removed by transnasal endoscopic techniques. Certain types of cancers in this area are often first treated with radiation with or without chemotherapy. If a recurrent cancer develops in this location, however, surgery may then be the only option for potential cure. Select cases can be addressed via endoscopic techniques though some will require more extensive open surgery.
Certain brain tumors may extend down to involve the sinuses or may be directly accessible through the sinuses. Common examples include pituitary adenomas and meningiomas. Depending on the tumor location, these may treated with surgery, radiation, or both. Selected tumors can be removed though via transnasal endoscopic approaches.
Orbital & Optic Nerve Compression
Loss of vision due to pressure on the eye or the nerve that goes to the eye can occur for a variety of reasons; trauma, tumors (of the brain, eye, or sinuses), hormone disorders (such as hyperthyroidism or Grave’s Disease), and abnormal bone growth (ie. fibrous dysplasia). Sometimes initial treatment will include medical therapy to decrease the swelling on the eye or treatment of the underlying medical condition. Occasionally, surgery is required to decompress the eye or optic nerve in order to preserve and/or restore vision. Many times, this can be cone with minimally invasive transnasal endoscopic techniques.