At the base of the skull is a complex scaffolding on which the brain rests. There are openings of various sizes through which large vessels and important nerves – including the brain stem – pass to enter and exit the brain. Tumors growing here can originate from any of the nearby tissue types, such as brain, nerve, sinus, or bone tissue. These tumors lie deep in the head and can present themselves in the most difficult way: hiding in hollows, tangled in tissue, or coiled around vitally important neural or vascular structures.
Dozens of tumor types, unique for their diversity and location, appear at the base of the skull, and some are very rare. These include meningiomas, neuromas, angiomas, schwannomas, melanomas, and various types of carcinomas and sarcomas, in addition to pituitary and bone tumors, cysts, fibrous lesions, and many others.
Regarding the symptoms they cause, Dr. Manish points out that they are highly variable. “Tumors at the base of the skull can present a wide variety of symptoms depending on the location of the skull.”
Symptoms such as:
- Headache (headache).
- Loss of vision or hearing.
- Double vision.
- Facial pain
- Loss of balance.
- Difficulty to swallow.
- Trouble walking
- Even behavioral changes.
Skull base surgery in Delhi for tumors has advanced dramatically through the use of minimally invasive techniques. In the past, the operation of these tumors involved large incisions and consequent facial scarring. An extensive external approach meant a large facial incision and displacement of bones, these operations could be long and with prolonged hospitalizations.
Minimally invasive surgery allows the tumor to be accessed with an endoscope through cavities, such as the nose, SURGERY THROUGH NATURAL HOLES, and to significantly reduce the duration of surgery and restoration. These techniques are constantly being improved, which means that an increasing number of tumors can be targeted in this way. Other very promising techniques for these tumors are also emerging.
Brain surgery through the nose
Minimally invasive surgery allows an endoscopic approach through the nasal cavity, without the need to open the skull. This has many benefits compared to traditional surgery, which required opening the skull or face, such as: shorter duration, considerable decrease in hospital stay, the absence of facial scars, the significant improvement in functional results, as well as the possibility of operating areas that were previously inaccessible, and it is also possible to intervene in large tumors, considered untreatable until a few years ago.
The optical and endoscopic tools used in surgery through the nasal cavity allow high definition visualization through stereoscopic cameras with optical fibers, which allow the brain surgeon in Delhi to see the operative field three-dimensionally and in full color, with the image enlarged and in high resolution.
Finally, the use of control mechanisms (monitoring of the cerebral and facial nerves throughout the intervention) helps to avoid injury to them.
What is the skull base?
The skull base is the bony portion that supports the brain and separates it from the rest of the head. The nerves and vessels that go to the brain (cranial nerves) run through holes in the skull base. Below the skull base are the nasal structures, sinus cavities, facial bones, and muscles associated with chewing.
WHAT TYPE OF SURGEON SHOULD THE SKULL BASE OPERATE?
Traditionally, a neurosurgeon in Delhi treats pathologies that appear inside the skull base and otolaryngologists those conditions in the head that appear outside the skull base. The collaboration of different specialties: neurosurgeons, otorhinolaryngologists and head and neck surgeons allow us to tackle deep injuries that were previously difficult to resolve.
WHAT IS MODERN SKULL BASED SURGERY?
In the last decade, novel surgical techniques have allowed most surgeries to be carried out through the nostrils using an endoscope: the ENDOSCOPIC ENDONASAL APPROACH or NATURAL ORIFICE APPROACH.
An endoscope is a light instrument that provides visualization within a cavity. Each of the stages of the surgery (approach, tumor resection and reconstruction) are carried out through the nasal cavity without the need to open the skull. These surgeries are described as minimally invasive, and allow surgeons to perform more extensive surgeries.
The concept of modern skull base surgery comes from the intention of achieving less invasive procedures that result in a more favorable evolution of the patients. While endoscopic endonasal surgery may be the solution for most skull base tumors, it is not the solution for all tumors. The skull base surgeon must be versatile in order to offer the best approach for each situation.
We have experience in all types of skull base surgery and use a variety of surgical procedures and techniques to design the best surgery for each patient.
WHAT IS ENDOSCOPIC ENDONASAL APPROACH?
The Endoscopic Endonasal Approach is a minimally invasive approach to the skull base that has been refined and is used to remove skull base tumors and other injuries through the nose. ESA is developed using a telescope called an endoscope. A small area of the skull base is removed to allow direct access to the tumor, without manipulating brain tissue. The concept of surgery from the inside out, starting directly at the tumor and working it out, eliminates the need to move critical structures to reach the tumor.
WHAT IS TRADITIONAL SKULL BASED SURGERY?
There are different ways to approach the skull base. In the past, the preferred technique was the approach to the skull base from above (transcranial approach) and from below (transfacial approach).
The transcranial approach consists of incisions in the cranial soft tissue followed by removal of part of the skull bone (craniotomy). The brain is lifted up to reach the skull base. The bones of the facial skeleton can be temporarily removed to increase exposure.
The transfacial approach consists of incisions in the face or inside the mouth that provide access to the sinus cavities from below. By working both below and above the skull base, surgeons can remove the tumor at the skull base. Surgery results in a cosmetic defect of the skull base and dura (the covering over the brain) that needs to be repaired to prevent a loss of cerebrospinal fluid (fistula) and infection (meningitis).
THE TRADITIONAL SKULL BASE SURGERY IS STILL USED?
For most skull base pathologies, ESA is generally sufficient as a treatment. Anyway, there are situations where the traditional approach is still used. We combine the endonasal approach with other approaches in some specific injuries. This is the concept of 360º surgery around the skull base.
We prefer not to force an angle of the surgery. If a specific tumor can be completely removed using a single approach, such as endonasal surgery, then we choose that approach. Anyway, if part of the tumor is located beyond important structures, such as blood vessels or nerves, we prefer to remove all residual portions using a different corridor, which can be through a traditional approach.
We have experience in all types of skull base surgery and we use a variety of surgical approaches and techniques that allow us to design better operations for each patient.
WHAT HAPPENS BEFORE ENDOSCOPIC ENDONASAL SURGERY?
If surgery is recommended, some additional studies should be done. This includes endocrinological, ophthalmological and laboratory evaluations. Before surgery, Tomography and / or MRI of the region are requested.
HOW LONG DOES ENDOSCOPIC ENDONASAL SURGERY TAKE?
The surgical time depends on the complexity of each case. In routine cases, the surgery takes about 2 hours from the time the anesthesia is administered. Other more complex cases can take between 4 and 6 hours.
IS THE SURGERY PAINFUL?
Skull base surgery in Delhi is much less painful and less uncomfortable than traditional approaches. Most patients control pain with traditional pain relievers, and are discharged without pain. The most common complaint has to do with postoperative nasal tamponade, which is rarely used in the endoscopic approach, unlike traditional surgery.
WHERE WILL I BE TRANSFERRED AFTER THE SURGERY?
After surgery, the patient is transported to a common room. Rarely, and only in specific situations is the patient admitted to Intensive Care. This has to do with the patient’s age, other concomitant diseases, or complexity of the surgery. Once the patient is awake and oriented, the family is admitted.
HOW LONG SHOULD I STAY INTERNAL?
Most patients are discharged after a two-night hospital stay. Of course, there are situations in which patients may need longer observation, as well as in other cases the patient is discharged the day after skull base surgery in Delhi.
WHAT SHOULD I EXPECT AFTER EE SURGERY?
In routine skull base surgery in Delhi, a nasal plug is not used. In the event that a tamponade is placed, once removed between the first and third day of surgery, the patient is instructed to place nasal drops several times a day, in order to dissolve the crusts in the nose. By the third postoperative month, healing is usually complete. Subsequent follow-up will depend on the diagnosis, symptoms, and need for additional treatments.
During the first month, patients should avoid activities that increase the pressure of cerebrospinal fluid inside the skull (stooping, carrying weight, blowing the nose) in order to minimize the risk of fistula. The fistula is characterized by the loss of clear fluid through the nose. If a cerebrospinal fluid fistula is confirmed, it can be repaired if necessary using the same endoscopic approach.
Patients may feel a decrease in smell or taste for several months after surgery, due to less air entering through the nose. This recovers as healing occurs.
WHAT IS THE POSSIBILITY OF HAVING A FISTULA THAT REQUIRES NEW SURGERY?
The possibility of suffering a postoperative fistula is low, and the need for a new surgery is close to 2%. In the case of more invasive tumors, such as meningiomas or craniopharyngiomas, it is slightly larger. With the development of the nasoseptal flap (vascularized tissue obtained from the patient’s own nose that is transplanted from the nasal septum to the skull base, the chance of fistula is around 5%.
WHEN CAN I RETURN TO WORK?
In general, patients are walking the day after surgery. In any case, postoperative rest is important to achieve proper healing. In cases of pituitary tumors, the patient returns to activity within a few days. In general we recommend avoiding weight bearing for a few weeks to get the cranial base reconstruction sealed.
ENDOSCOPIC SUPRAORBITARY APPROACH FOR SKULL BASED INJURIES
Access to tumors of the anterior cranial fossa traditionally required extensive exposure of the surgical field, along with prolonged retraction of the frontal lobes or cosmetically disfiguring transfacial approaches.
These approaches subjected the patient to undesirable neurological sequelae and cosmetic morbidities. With the introduction of progressively less invasive approaches, intracranial tumors involving the craniofacial mass have been able to be resected on bloc with minimal consequences. Among these approaches is the supraorbital endoscopic approach. This technique is indicated in lesions located in the region of the anterior cranial fossa, and in the sellar and suprasellar regions, which include meningiomas, craniopharyngiomas, pituitary tumors with selar and suprasellar extension, and other supratentorial pathologies.
The use of endoscopes allows a deep visualization of all the critical paramedian structures of the skull base without the need for a bifrontal cranial approach, wide bone resections or brain retraction. The cosmetic results are excellent and the complications are minimal.
It has been shown that the application of endoscopy to anterior skull base and craniofacial mass surgery can eliminate the need for traditional open surgery, while maintaining a high success rate of skull base surgery in Delhi.