Surgery is the primary treatment modality in benign tumors of the nose, sinuses and anterior skull base. Radiation therapy and chemotherapy are use in conjunction with surgery for extensive malignant disease. In some malignant tumors, such as lymphoma, radiation therapy and chemotherapy are the primary form of treatment. The decision to combine surgery with other treatments reflects: 1) the location, extent and ability to remove a tumor, 2) the biological behavior of the tumor, and 3) the morbidity to the patient in attempting removal.
One of the oldest surgical approaches to removing tumors of the sinuses is the lateral rhinotomy. This consists of incising the facial skin from the inner aspect of the eye lids (medial canthus), along the nose and through the upper lip (incision 1). This permits exposure of the upper jaw or maxilla, nose and anterior skull base. As this approach further evolved, and when the tumor is confined to the nose or medial (inner) wall of the maxillary sinus, exposure is possible by incising within the mouth above the gums and elevating the skin and muscle over the maxilla and nose (incision 3). This degloving approach avoids facial incisions and permits the resection of many benign and some malignant tumors.
As some nose and sinus tumors invade the anterior skull base, the bone which separates the brain from these sites, surgical approaches were developed to combine traditional neurosurgical procedures with the above facial surgeries. Collectively, such procedures are known as craniofacial surgery, and these vary with the experience of the surgeon and the type and extent of the tumor. Of these various procedures, we prefer the transcranial approach because it provides excellent exposure of the skull base, brain, orbits and sinuses without involving facial incisions (incision 2).
Such a patient is illustrated by the intraoperative photograph of the right nose showing a benign tumor (T) arising from the nasal septum (NS) and deforming the right middle turbinate (MT). The coronal MRI of this patient shows extensive tumor involving the nasal septum, sphenoid sinus, and extending into the cranial cavity and encasing the internal carotid arteries.
This tumor was safely removed using a transcranial craniofacial approach. The disadvantage of all craniofacial approaches is that they involve some form of a craniotomy, or opening the skull to the brain cavity, and may be poorly tolerated in elderly patients.
Most recently endoscopic nasal approaches have been developed to remove many of the benign, and selected malignant tumors, of the sinuses, nose and skull base. The advantage of these approaches is that they are minimally invasive. Minimally invasive surgery implies that a procedure is performed with least disruption of normal tissues and structures yielding the least patient morbidity.
As an example, minimally invasive surgery of the knee joint or arthroscopy is performed by an endoscope which is use to visualize the knee joint and guide the surgeon in the repair of ligament or cartilage surgery. The knee is examined using a small puncture wound for the endoscope and another puncture for the surgical instruments. In contrast, the same surgery prior to endoscopes was performed by an external incision through the skin, ligaments and muscles of the knee. This left the patient with the morbidity of the approach which often led to poor mobility of the knee. However, such approaches require special training and in the case of nasal and skull base tumors there are special considerations.
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