3D endoscopic endonasal craniectomy for intestinal type adeno-carcinoma (ITAC) of the nasal cavity

Abstract

Background: The aim of this study was to describe the potential advantages of the 3D endoscope-assisted craniectomy for tumor of the nasal cavity.

Methods: A 77-year-old man with a 6 month history of persistent progressive right nasal obstruction and iposmia is reported. Physical examination, including nasal endoscopy, revealed a large mass within the right nasal cavity. He had no associated symptoms such as visual complaints, paresthesia, and facial pain. He worked as a carpenter. Further imaging by CT and MRI revealed a large, expansive nasal-ethmoid lesion that almost completely occupies the right nasal cavity with partial extension posterior to the choana, extensive erosion of the ethmoid. Medially marks the nasal septum with deviation to the left. Laterally it marks the medial wall of the maxillary sinus and at the top it is in contact with the cribriform plate which seems to be interrupted in the right parasagittal seat at the 3rd anterior of the olfactory cleft. Histopathological analysis of the specimen was consistent with sinonasal adenocarcinoma, intestinal type (ITAC) cT4aN0 ([1]).

Results: Patient was taken up for surgery by transnasal 3D endoscopic approach for excision of tumor with repair of the skull base defect, using Karl Storz IMAGE1 S D3-Link™ and 4-mm TIPCAM®. The mass could be dissected free of the dura and the entire specimen was removed completely and sent for histopthological examination. We followed our 8 main surgical steps: 1) Tumor disassembling; 2) Nasal septum removal; 3) Centripetal bilateral ethmoidectomy and sphenoidotomy; 4) Draf III frontal sinusotomy 5) Anterior and posterior ethmoidal artery closure 6) Skull base removal; 7) Intracranial work; 8) Reconstruction time. A 4 × 2.3 cm skull base defect was repaired using triple layer of fascia lata (Intracranial intradural, intracranial extradural and extracranial) and was sealed using tissue glue (Tissel^R). Post-operative recovery was uneventful, pack were removed on 3rd postoperative day and patient was discharged on the 7th post-operative day. After 2 years of follow up, the patient is free of disease.

Conclusion: We describe 3D endoscopic transnasal craniectomy for Intestinal Type Adeno-Carcinoma (ITAC) of the nasal cavity as a feasible technique for the surgical management of sino-nasal tumors ([2].) Our experience with this approach has been outstanding. We firmly believe that in the first three steps of the procedure the 3D endoscope is not necessary because it extends the surgical time and induce eyestrain of the main surgeon. Nevertheless, 3D endoscope gives the major advantage during the skull base removal and the intracranial work. It offers an optimal vision and better perception of depth with safe manipulation of the instruments avoiding injuries to healthy tissue ([3]). Furthermore, 3D images offer better understanding of the relationship between anatomical landmarks, helping the didactic learning curve of our residents.

Keywords: 3D endoscope; Craniectomy; Intestinal type adeno-carcinoma (ITAC); Nasal cavity; Skull base.