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Brain Surgery: Through the Nose

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Brain Surgery: Through the Nose

By Tiffany Johnson. CREATED Aug 28, 2014

CLEVELAND (Ivanhoe Newswire) - Removing a brain tumor can be tricky for surgeons and painful for patients. Now there’s a new way to take out these lesions as surgeons are using the nose as a pathway to the brain.

A few months ago just walking his dog would have been too much for Robert Matthews. Tests showed that he had a large, non-cancerous tumor pressing on his brain.

“I wasn’t stable walking. My speech was slurred. I used to always have these migraines, and they were bad.” Matthews told Ivanhoe.

His doctor said he needed a craniotomy which involves making a large incision to open the skull and going deep in the brain to remove the tumor, but then Cleveland Clinic surgeons told him about a new option.

“Essentially, we use the nose as a channel or a pathway to get up to the brain,” said Dr. Raj Sindwani, Otolaryngologist at the Cleveland Clinic.

Two surgeons enter through the patient’s nose and cut a tiny opening in the brain covering. They use special instruments to remove the lesion through the small hole. Instead of a cut from ear to ear, the internal incision is just two centimeters. Surgeons don’t have to disrupt the frontal lobes in the brain. That means less pain and a faster recovery, four to six weeks instead of three to six months.

“These surgeries are like a finely orchestrated dance. They require two surgeons to be operating, with four hands through the nose.” Dr. Recinos, Neurosurgeon at the Cleveland Clinic told Ivanhoe.

Matthews hasn’t had any symptoms since his surgery. Now he can enjoy his pets without any pain.

Not everyone with a brain tumor is a candidate for this procedure. The patient’s tumor has to be at the base of the skull. Although this surgery is less risky than a craniotomy, there is a chance patients could lose their sense of smell or experience a decreased sense of smell.

RESEARCH SUMMARY

BRAIN TUMORS: When cells become old, they die off and get replaced with new cells. Sometimes, something disrupts this process and the old cells that your body doesn’t need any more continue to grow until they develop into a mass of tissue. This mass of tissue is known as a tumor. Primary brain tumors, meaning they start in the brain, can either be malignant or benign. A tumor arriving from the brain’s meninges is called a meningioma. While benign tumors are non-cancerous, malignant tumors are cancers that grow and spread aggressively throughout the rest of the brain. Though benign tumors are generally non-life-threatening, any tumor that develops in the brain can be a major health risk, as it’s putting too much pressure on the tissue inside the skull. Metastatic tumors are tumors found in the brain that formed elsewhere in the body. (Source: http://www.webmd.com/cancer/brain-cancer/brain-tumors-in-adults)

TREATMENT: Brain tumors are treated with surgery, radiation therapy and chemotherapy. Treatment for brain tumors is based on several different factors including age, medical history and the tumor’s size and location. If surgery cannot be performed, doctors may treat the tumor with radiation from X-rays to destroy tumor cells or slow tumor growth. After each treatment, long-term plans are developed to monitor for any possible future tumor formation or growth. (Source: http://www.braintumor.org/brain-tumor-information/treatment-options/)

NEW TECHNOLOGY: Brain surgery is an extremely risky procedure and can be very painful for the patient. There’s now a new option to perform brain surgery that uses the nose to get to the brain. Unlike the standard craniotomy, a risky procedure involving a large incision through the skull to access the brain, transnasal endoscopic skull-base surgery is a completely new procedure that’s less invasive and has a shorter recovery time. Surgeons access the brain through the nostrils, remove the tumor and repair and damaged tissue. To be a candidate for the procedure the patient’s tumor must be at the base of the skull. (Source: http://cleveland.cbslocal.com/2014/05/29/surgeons-performing-brain-surgery-through-the-nose-2/)

INTERVIEW

Pablo Recinos, M.D., Section Head of Skull Base Surgery, Cleveland Clinic and Co-Director of the Minimally Invasive Cranial Base and Pituitary Surgery Program.

Can you tell us about skull base surgery through the nose and how it’s done?

Dr. Recinos: Skull base surgery in general is using corridors that involve removing bone to approach difficult areas at the base of the skull. The principle behind it is to remove more bone and retract or disrupt the brain as minimally as possible. By doing that, the patient doesn’t experience the bad effects from retracting on the brain while still being able to get a procedure done to approach a tumor in a very difficult to reach location. Now, minimally invasive skull-based surgery or skull base surgery through the nose is precisely that; just finding bony corridors that allow you to approach a tumor more directly without disrupting the brain. There’s still bony drilling and bony corridor removal to approach the tumor. It’s just through one of the body’s natural openings.

Clearly everything goes through the nose so everything must be very tiny and you must use cameras. How does it work and what kind of tools do you use?

Dr. Recinos: Minimally invasive endoscopic surgery through the nose first starts with a telescope called an endoscope. It’s a very long instrument which allows us to gain visualization at the end of the scope so it’s a very close up view. The next instruments are the specially designed micro instruments that fit through the nose, some of them with angles to approach hard-to-reach places mirroring a lot of the standard surgical equipment that we already use, but just on a scale that is elongated so we can use it through the nose. It works like a finely orchestrated dance. It requires two surgeons to be operating at the same time.

You said it was like a finely orchestrated dance?

Dr. Recinos: Yes, they require two surgeons to be operating with four hands through the nose. If you can imagine, that’s a very tight space and requires both surgeons to be moving in sync and to follow certain rules so we can work together as opposed to stepping on each other’s feet so to speak.

That’s teamwork at its best.

Dr. Recinos: It requires a good partnership for sure.

Who is the ideal candidate for this type of surgery?

Dr. Recinos: The most common patients that have these types of procedures are patients with pituitary tumors, but really any patient who has a tumor at the base of the skull is one that should be considered. Now that doesn’t mean every patient is appropriate for these types of approaches. By using these approaches we’ve been able to either do the approach by itself to reach these hard to reach locations or to combine it with other traditional approaches to provide a more complete tumor resection for the patient. So it’s all patients that have skull-based tumors that can be considered, it’s just a matter of deciding which one of them is appropriate.

So the tumor has to be at the base of the skull, is it always a cancerous tumor or can it be a benign tumor as well?

Dr. Recinos: We see both cancerous and benign types of tumors that we can approach through the nose. The more common brain tumors so to speak tend to be benign in this location and can arise anywhere from behind the middle part of your forehead all the way to where your head sits on your spine. Any benign tumor that arises in that location is a good candidate for this type of surgery. Cancers that arise from the nose themselves and start invading bone and get into the brain space are also good candidates for these types of procedures.

So when does this type of surgery become necessary? Does the tumor kind of grow to the point where it interferes with daily activity? When is something like this necessary for a patient?

Dr. Recinos: So with every patient we take an individualized approach. We have to weigh the risks and benefits of doing a surgery to begin with like you would with any procedure. If we’re talking about benign tumors we have to really make sure that tumor is starting to grow or pushing on critical structures such as the optic nerves. In cases where you have patients that are impaired or losing vision for example it’s a pretty easy call. In other situations you have to appropriately counsel the patients and sometimes that means following the patients before you decide to do any intervention.

What options did patients in this situation have before this surgery came about?

Dr. Recinos: For larger tumors in a lot of these hard-to-reach places the previous options involved large incisions that involved removing a large window of bone or window of the skull to approach those tumors. There were also radical approaches that would involve coming from the side through somebody’s neck and through a lot of critical structures. They were very aggressive and radical approaches to get to these locations. I think that the opportunity to use the body’s natural corridor just so happens to provide us access to some of the hardest to reach places through more traditional skull base approaches.

How many other centers do this type of surgery?

Dr. Recinos: There are a slight number of centers across the country that do this type of surgery. It’s far more common to have centers doing pituitary surgery through the nose but for more extended cranial base approaches there are not a whole lot of centers across the country. I think the main reason is that it really does take a village so to speak. You need the right partnership with an ENT and a neurosurgeon or an otolaryngologist and a neurosurgeon. You need the appropriate resources at the hospital, from nursing care to the operating room equipment. To bring all those together really requires that the otolaryngologist and the neurosurgeon be dedicated to treating these types of problems. I think that’s probably one of the reasons why we don’t see it more widespread than it is.

What would you say are the advantages for the patient doing it this way rather than one of those radical ways?

Dr. Recinos: I think minimizing morbidity or bad side effects that we would get from traditional surgery is probably the largest advantage of minimally invasive skull base surgery. The fact that you can approach very large tumors without having to retract off somebody’s brain shortens hospital stays. That improves recovery time for the patients to get back to work and I think those reasons alone are huge advantages over previous open approaches.

What’s the recovery like?

Dr. Recinos: After their surgery, patients can be in the hospital for a few days. Anywhere between two and four days is standard for these types of surgeries. The main thing that we limit is to not do anything strenuous to jeopardize the repair that we’ve performed, but those patients are up eating, walking around, interacting with their loved ones and back to work in a little over a month typically.

How long have you been doing this here at the clinic?

Dr. Recinos: These types of surgeries were really started in January of this year. That was when I came and I was fortunate to partner with Rosh and Quanah from otolaryngology that helped spearhead this initiative here at the clinic. I also partner with Dr. Troy Woodard from ENT to do these types of procedures.

Are there any specific risks associated with this type of surgery that wouldn’t be common in all surgeries?

Dr. Recinos: Sure. If we would compare open skull base surgery to endonasal surgery the main difference in risk profile is probably risk to the nose. Specifically things like sense of smell, there is a risk that patients can have decreased or even loss of sense of smell. Now with certain tumors, the open approaches might risk the sense of smell as well but that certainly is one that would apply to most of the procedures that we do through the nose. There’s also a certain maintenance that needs to be done from the nose. My ENT partners will see the patients and follow-up to make sure that their nose is healing right, the patients have to do nasal sprays and things to ensure that they are healing appropriately.

What if this surgery wasn’t available?

Dr. Recinos: Robert essentially had two options to treat his tumor. His tumor arose from the base of the skull just underneath where the frontal lobes of the brain set. The traditional option would’ve meant having a procedure that involved making an incision from one ear to the other ear across the top of his head and allowing us to create a large window or a large opening in his skull in the front part of his brain. That would be followed by gently moving the two frontal lobes aside to gain access to the tumor. The problem with that approach is that you have to move the brain for hours in order to do the tumor removal. By going through the nose we created a similar direct corridor without having to move aside any parts of brain and we got directly to the tumor at the very beginning of the surgery. The blood supply of the tumor itself came from the bottom which was the first thing that we were able to control by coming through his nose. By choosing the trans-nasal or minimally invasive approach with Robert we were able to control tumor bleeding from the beginning. We were able to avoid having to retract the lobes of his brain to approach the tumor and at the end still achieve a very complete tumor removal without having disrupted his brain at all and having the associated risks with that.

Are you able to get more of the tumor this way or is it about the same as some of these other ways?

Dr. Recinos: It really depends on each specific example. In Robert’s case the things that are predictive of the patients having the best outcome are to remove the entire tumor, through removing an extended part of the brain covering called the meninges and to remove the bone on which this sits. Now in his case we were able to do all of that probably much easier from the trans-nasal approach than we would have from a traditional approach. So that’s not to say it couldn’t have been done through an open approach but in this case it was actually easier to achieve those same goals to give Robert the best chance at not having any tumor recurrence in the future.

He had a benign tumor?

Dr. Recinos: That’s correct. Roberts’s tumor was a meningioma. Meningiomas arise from the meninges or the brain covering and they typically will grow slowly over time. The problem in Robert’s case is that the tumor had grown to such a large size where it was pushing his frontal lobes and was displacing them to the sides and he was already starting to feel the effects of that. He was getting to the point where his energy was down, he was not able to concentrate very well, he was not working and those are all things that would have just continued to become worse over time. With Robert being such a young person, that’s not an outlook that you would want to have for the rest of your life. It certainly was a good reason for the tumor to come out.

How is he doing now?

Dr. Recinos: Robert’s doing great. It’s just such a joy for us as physicians to be able to see when our patients are doing well. The personal satisfaction that we derive isn’t when we do a good job but it’s when patients do well. To see Robert smiling, happy, going back about his normal business, he’s starting to work again and it’s just so gratifying.

If there’s somebody out there watching this story that may be thinking about this or this might be the first time they’re hearing about it what would your message to them be about the procedure?

Dr. Recinos: I think that minimally invasive skull base surgery is a wonderful advancement in the field of treatment of skull based tumors and brain tumors in general. I would say that it’s important to seek out a center such as ours where people are doing it really as a routine because you want to make sure that your team is experienced doing these types of surgeries. I think it’s important that the surgeons are seeing tumors that also are not appropriate for these procedures so that they are able to make the distinction between which tumors are appropriate for this technique and which are not. I would certainly urge them to seek a consultation at a place where they’re doing it as a matter of routine.

Do patients usually need chemo, radiation, or other additional treatments?

Dr. Recinos: Patients can need additional treatments such as chemotherapy and radiation. It really depends on what the pathology is, whether it’s benign or cancerous. Even some benign tumors for example, meningiomas can require further radiation in the future. That’s actually an advantage that we have a lot of different options in our tool belt to be able to treat some of these tumors, whereas before options were much more limited. For cancerous tumors that arise from the nose, invasive chemotherapy and radiation can play a central role in their treatment.

FOR MORE INFORMATION, PLEASE CONTACT:

Andrea Pacetti
Apacetti1@gmail.com
216-444-8168