1. Endoscopic vs Open Sino
Nasal & Anterior Skull
Base Surgery
Ajay Manickam

2. INTRODUCTION

3. Contraindication
• Facial soft tissue/ Ant wall of Frontal bone
• Orbital Apex / Lat to optic tract/ B/L Optic nerve
• Cavernous sinus / ICA
• Tumours needing Dissection along the cranial Nerve
• Gross Brain involvement
• LONDON CANCER ALLIANCE and castelnuvo
(paper)

4. TNM Staging
•Maxillary
•Ethmoid and Sinonasal Malignancy

5. Endoscopic Surgery
•Enbloc Resection & Clear Margins
•Histopathology - Not the same
•Large vessel Bleed
•Repairing Dura

6. Endoscopic Surgery
•Visualisation
•Site of attachment
•No need For Brain Retraction
•No Facial Incision
•Complications less
•Shorter Hospital stay
•Less Cost

7. Dogma
• Tumour needs Enbloc Clearance -
Local Control
• Clear Margins can be achieved only
through Open approach

8. 1) Is En Bloc Mandatory?

9. En bloc resection
• Enbloc resection is not necessary

10. En bloc Resection
En bloc excision of the entire tumor is not necessary rather en
bloc excision of the area of invasion is performed.
• Olfactory Neuroblastoma

11. Retrospective review of patients with sinonasal
malignancy managed via endoscopic techniques
from September 1998 to December 2007 was
conducted.(University of Texas)
Despite concerns of piecemeal resection
resulting in higher recurrence rates, The overall
and local recurrence rates were 31 and 17%,
respectively.

12. Brain involvement can never be cleared with margins.
In short the sinonasal and anterior skull base tumours the margins are close
and usually ‘gross total resection’ is possible at best.
Dural margins are assessed with frozen section

13. 2) Histopathology - Not the
same

14. Not the same
The 5-year disease-specific survival rate for all tumor types was 60%.
Overall survival at 5 years
Esthesioneuroblastoma (78%)
Low grade sarcomas (69%)
High-grade sarcomas (57%)
Adenocarcinoma (52%)
Salivary malignancies (46%)
Squamous cell carcinoma (44%)
Undifferentiated/ anaplastic carcinoma (37%)
Mucosal melanoma (18%)

15. HPR
•Endoscopic endonasal surgery represents an
oncologically sound alternative to opensurgery in
selected patients with sinonasal malignancies with lower
morbidity, faster recovery, and better quality-of-life
outcomes.

16. HPR - SARCOMA
Retrospective review of the literature on sinonasal
sarcomas from 1987-2017. Data were analyzed for
demographics, treatment type, stage, and histopathologic
type. Kaplan-Meier analysis was used to assess and

17. On univariate analysis T stage, overall stage, treatment
type, histopathologic subtype, and presence of distant
metastasis significantly affected survival.
On multivariate analysis overall stage alone significantly
predicted overall survival. Open vs. endoscopic surgery,
total radiation dose, and presence of neck metastasis did

18. A monocentric(France) retrospective study was carried out
from May 2002 to December 2013, including 43 patients
with intestinal-type adenocarcinoma of the ethmoid sinus.LR
and ESS were performed in, respectively, 23 and 20 patients.
The two groups were comparable in terms of age,
occupational dust exposure, histopathological sub- types,
and T stage based on the pathological assessment of the
specimen

20. ESS is a valid option even for local advanced tumours in
close vicinity to the anterior skull base.
The intraoperative assessment of tumour extensions is
more relevant than CT scan and MRI to determine the
feasibility of this surgical approach.
A complete centripetal removal of the ethmoid labyrinth is
mandatory to circumscribe the ADC origin frequently

21. Retrospective review of the medical records of
25 patients with sinonasal mucosal melanoma
(SNM) treated by either OR or ER. - Cleveland
clinic

24. The proportion who achieved negative surgical margins on resection
(54% [n = 7] vs 58% [n = 7]) (P = .82) were similar between two
groups .
Overall all median survival (12.7 and 1.9 years) (P = .87) and
disease-free survival (1.9 and 1.2 years) (P = .72) were modest and
did not differ between OR and ER groups

25. Thirty-six studies containing 609 patients were included.
Meta- analysis of (a) all patients, (b) Kadish C/D only, and (c)
Hyams III/IV only, failed to show a difference in locoregional
control and metastasis- free survival between approaches.
Endoscopic approach showed improved overall survival (OS) for all
3 groups (p = .001, .04, and .001, respectively), and higher disease-
specific survival (DSS) for all patients (p = .004) and Hyams III/IV
only (p = .002).

26. 3)Bleeding
The giant JNA’s remodel the adjacent greater wing of
sphenoid and the orbital apex expanding the inferior orbital
fissure and spread intracranially alongside the cavernous
sinus.
The treatment of choice is complete excision with drilling
of the sphenopalatine region. This can be done via external
or endoscopic approaches.

27. 4) Repair1.Villaret AB, Yakirevitch A, Bizzoni A, et al. Endoscopic transnasal
craniectomy in the management of selected sinonasal malignancies.
Am J Rhinol Allergy 2010; 24:60–5.
2.Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive
technique after endoscopic expanded endonasal approaches: vascular
pedicle nasoseptal flap. Laryngoscope 2006;116(10):1882–6.
For the first intradural layer of duraplasty, the graft has to be at least
30% larger than the dural defect
The second layer, intracranial and extradural, needs to be precisely sized
and tacked between the previously under- mined dura and the residual
ASB bone
For the third layer of the skull base reconstruction it is also possible to
use a mucoperiosteum/mucoperichondrium pedi- cled nasoseptal flap
(Hadad-Bassagasteguy flap)

28. Endoscopic surgery

29. prospective cohort study, after histological confirmation and a staging
imaging protocol, patients deemed suitable were offered the option of
an entirely endoscopic resection as an alternative to craniofacial
resection. The procedure was performed under frozen section
control.
Hospital stay was a mean of 5 days, with no significant postoperative
complications

30. A retrospective analysis of patients treated by an exclusive endoscopic
approach (EEA) or a cranioendoscopic approach (CEA) from 1996 to
2006 managed by two surgical teams at the Departments of
Otorhinolaryngology of the University of Brescia, and the University of
Pavia/Insubri Varese, Italy.
n=184.
EEA in 134 patients and the CEA in 50 patients.
The most frequent histotypes encountered were adenocarcinoma
(37%), squamous cell carcinoma (13.6%), olfactory neuroblastoma
(12%), mucosal melanoma (9.2%), and adenoid cystic carcinoma
(7.1%)

31. The distribution of tumors in relation to T category
52 (28.2%) T1 (49 and 3 in the EEA and CEA group,
respectively), 26 (14.2%) T2 (25 EEA and 1 CEA),
32 (17.4%) T3 (20 EEA and 12 CEA),
17 (9.2%) T4a (9 EEA and 8 CEA), and
35 (19%) T4b (12 EEA and 23 CEA

34. The 5-year disease-specific survival was 81.9 􏰌for the
entire patient cohort, varying from 91.4 􏰌% for the EEA
group to 58.8 􏰌% for the CEA group (p 􏰌 0.0004).
In the EEA group, 5-year disease-specific survival was
94.4 􏰌 for adenocarcinoma, 60.7 􏰌for squamous cell
carcinoma, and 100% for adenoid cystic carcinoma (p 􏰌
0.03)
Conversely, in the CEA group, 5-year disease-specific
survival was 57.9 for adenocarcinoma, 53.3 􏰌 for
squamous cell carcinoma, and 100% for adenoid cystic
carcinoma (p 􏰌 0.8).

35. Comparison Open vs
Endoscopic

36. A retrospective chart review was performed of patients with
sinonasal or skull base malignancies treated with endoscopic
or endoscopic-assisted resections at a tertiary care institution
from 2002 to 2010.
Patient data were collected on symptoms, tumor type,
operative technique, and postoperative course.
Baseline risk factors, overall and disease-free survival data,
and surgical outcomes were compared between the two
groups.

40. The 5-year overall survival was 87.4% (SE ± 5.3) in the endoscopic group vs
76.8% (SE ± 8.3) for open approaches (p = 0.351), disease-specific survival
was 94.7% (SE ± 3.7) vs 87.7% (SE ± 6.7; p = 0.258); and locoregional
control rate was 89.5% (SE ± 5.0) vs 77.2% (SE ± 10.4; p = 0.251).

41. The National Cancer Database was queried for cases of sinonasal
squamous cell carcinoma (SNSCC) with- out cervical or distant
metastases that were treated surgically between 2010 and 2014.
They were split into 2 groups based on surgical approach: open or
endoscopic. Demo- graphics, facility and insurance type, stage, tumor
characteristics, postoperative treatment, 30-day readmission rate, 30-
and 90-day mortality, and overall survival (OS) were compared
between the 2 groups.
Propensity score matching (PSM) was used to mimic a randomized,
controlled trial.

44. Margins
No difference in the rate of positive margins, both
before and after matching, between the endoscopic and
open groups. This suggests that the ability to attain an
R0 resection is comparable between surgical techniques.
There have been no previous studies comparing margin
status for endoscopic vs open resection specifically for
SNSCC
Hospital stay was significantly shorter in patients treated
with endoscopic resection (endoscopic: 2.50 days; open:
4.67 days; p < 0.0001).

45. Shorter stay
Endoscopic surgery to be associated with a significantly
shorter length of stay (in the matched cohort of this
study, length of stay was 2.54 days for endoscopic
surgery and 4.69 days for open surgery).
This is a major advantage of endoscopic surgery, given
that a shorter hospital stay is associated with not only
lower cost, but also a decreased risk of hospital-
associated morbidity such as healthcare- associated
infections

46. Conclusion
A PSM cohort of 652 patients with SNSCC treated
with endoscopic or open resection revealed no
difference in OS between matched groups, and
significantly shorter hospital stay in the endoscopic
surgery group.

47. Complications
TER patients had shorter operating room times, lower
intraoperative blood loss, shorter ICU stays, and shorter
hospital stays. There were no differences for the rates of true
en bloc resection (minimally ascertainable in either group),
negative margins, or disease-specific mortality.
There were no significant differences in disease- specific
mortality or recurrences.

48. Progress

49. Endoscopic vs Open Sino
Nasal & Anterior Skull
Base Surgery
Ajay Manickam

50. Thank You
I will not be ashamed to say “I know not,” nor
will I fail to call in my colleagues when the skills
of another are needed for a patient’s recovery.”