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Even Brain Surgery can be Minimally Invasive: Using Nasal Passages as Access for Removing Certain Brain Tumors

Minimally invasive surgery has made great strides over the past few decades. Many surgeons prefer this method of treatment for their patients because it shortens recovery time and results in less trauma to the body compared to traditional open surgery. Minimally invasive surgery has saved many lives, especially for patients who have had to undergo something as serious as the removal of a brain tumor.

The endoscopic, endonasal approaches for removing skull base brain tumors involves a partnership between neurosurgeons and ear, nose and throat (ENT) doctors. The latter of which pioneered use of the endoscope, a rigid, glass lens tube used for minimally invasive internal imaging.

G. Michael Lemole Jr., MD, is the director of the Vickie and Jack Farber Institute for Neuroscience at Abington – Jefferson Health, and is nationally recognized in the field of neuro-oncology and skull based surgery. Dr. Lemole provides some insight into this approach to brain tumor removal.

Q: What exactly is endoscopic, endonasal surgery?

Dr. Lemole: Nasal passages provide us with a naturally occurring corridor to the brain. With endonasal, endoscopic surgery, we don’t have to make a big incision or risk cosmetic side effects, and we also don’t have to move brain, nerves or blood vessels out of the way to reach certain tumors. During surgery, the neurosurgeon and ENT will work together to position the endoscope correctly to get a good view of the tumor.

Technology is always evolving, and we’ve been able to get better and better endoscopes throughout the years. Better neurosurgical navigation means we can get where we’re going a little bit faster and safer. More hospitals are transitioning to higher resolution imaging using endoscopes, which gives an excellent picture of the space where we work. And I want to note that minimally invasive doesn’t mean minimally effective. We’re not trading efficacy for minimally invasive surgery.

Q: Who are the ideal candidates for this surgery?

Dr. Lemole: In order for us to use endoscopic, endonasal surgery, the tumor must be located in the region of the brain just above and behind the nose. Fortunately, a fair percentage of tumors are located in the right spot to use this method, including pituitary tumors, tumors that may develop as a result of smoking and other benign tumors. But if the tumor is behind the ear, on top of the head or deep within the brain, we’ll use a different method to reach it. The key is finding the right tool for each particular patient’s condition and needs.

Aside from location, we look at the type of tumor and its natural history, as well as the patient’s desires, needs and expectations. If we’re treating a young person with a pituitary tumor as a result of Cushing’s Disease, which could destroy their life, we’re inclined to use this method to remove the tumor completely. But for someone older with a non-threatening, benign tumor, they may not want to take the risks of surgery at all. There are many factors that go into deciding what’s best for each and every patient.

Q: Are there risks associated with this surgery?

Dr. Lemole: In general, this is a high-risk area to operate on because the base of the skull is where the nerves and blood vessels enter and exit the braincase. The particular risk factors depend on the exact location of the tumor. The optic nerves are located just above the pituitary gland, so if we’re working on that area there’s a low risk for blindness or other vision problems. If we’re near the carotid artery there may be a risk for bleeding. We could also work near the nerves that control facial sensation, causing numbness or pain in that area. Similarly, if we’re working near the olfactory nerves, we may have to damage them to reach a tumor. That being said, all of these complications are rare with minimally invasive surgery and an experienced surgeon.

More common (albeit still rare) risks are brain fluid leaks, which can happen where a tumor has been removed, from trauma or from previous surgery. This happens when the thick leathery sack that the brain sits in—called the dura mater—has been violated. If you have a leak, the brain will start to sag instead of float on the fluid inside and it will lead to debilitating headaches. A leak can also make it easier for bacteria from the nose to enter the brain, which can result in meningitis.

Q: What’s the recovery process like after this surgery?

Dr. Lemole: Most minimally invasive procedures can be completed in just a few hours, and as long as there are no complications, patients can go home within two to three days after their surgery. For endoscopic, endonasal procedures specifically, patients don’t have a lot of pain but they might experience nasal stuffiness or crusting in their nose. Regular nasal irrigation and ENT follow-ups are important to keep these patients healthy. If their surgery required us to open the lining of the brain, they’ll need to stay away from strenuous activities for a little bit longer while the repair heals so that they don’t develop a brain fluid leak.

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