Otolaryngology–Head and Neck Surgery (2007) 136, 920-927
ORIGINAL RESEARCH
Surgical outcomes and safety of transnasal
endoscopic resection for anterior skull tumors
Sandeep P. Dave, MD, Anthony Bared, MD, and Roy R. Casiano, MD,
Miami, FL
OBJECTIVE: To report the surgical outcomes and safety of
transnasal endoscopic resection (TER) for anterior skull base
(ASB) tumors.
STUDY DESIGN AND SETTING: A retrospective chart re-
view to identify patients undergoing TER for ASB tumors at a
tertiary care medical center between September 1997 and June
2006.
RESULTS: Nineteen patients underwent TER for ASB tumors
without open craniotomy. There were 17 malignant and two be-
nign lesions. Olfactory neuroblastoma was the most common pa-
thology, occurring in 53 percent of patients. One patient recurred
locally, resulting in an overall local control rate of 94.7 percent for
all neoplasms and 94.1 percent for malignant disease. It should be
noted that the tumor control rate may be premature given the small
sample size and limited follow-up. Overall, there were 16 compli-
cations, but only two of these, an orbital hematoma and a frontal
lobe abscess, were considered major complications directly attrib-
utable to surgery.
CONCLUSIONS: TER for ASB tumors appears to be safe in
properly selected patients. In light of the small sample size and
limited follow-up, the major complication rate directly attributable
to surgery was 11 percent, and the overall local control rate was 95
percent. A larger multi-institutional series with longer follow-up is
warranted.
© 2007 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
T raditional craniofacial resection (CFR), which com-
bines a bifrontal craniotomy and a transfacial approach,
has been the gold standard for treatment of anterior skull
base (ASB) neoplasms. However, this approach has been
From the Department of Otolaryngology–Head and Neck Surgery,
Jackson Memorial Medical Center and Sylvester Comprehensive Can-
cer Center, Leonard M. Miller School of Medicine, University of
Miami.
Dr. Casiano is a consultant for Gyrus ENT and Medtronic Xomed.
Presented at the Annual Meeting of the American Academy of Otolar-
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2007.01.012
associated with significant morbidity and perioperative mor-
tality.1-5
In the late 1990s, endoscopic-assisted CFR, in which the
ASB is approached via bifrontal craniotomy from above and
endoscopically from below, was first described.1,6-8 From
1999 to 2001, Stammberger et al,9 Walch et al,10 and Unger
et al11 reported a series of patients with olfactory neuroblas-
toma who were treated with a combination of transnasal
endoscopic resection (TER) and adjuvant stereotactic radio-
surgery. All tumors were removed piecemeal; in the major-
ity of cases, the ASB bone and the overlying dura were
preserved. Since then, several authors12-14 have reported
case reports describing TER for various ASB tumors.
In 2001, Casiano et al1 reported the first en bloc TER for
an ASB tumor that included both the skull base bone and
overlying dura, without the need for open craniotomy.
Three of the patients underwent a formal endoscopic resec-
tion, which included the crista galli, perpendicular plate,
cribriform plate, olfactory bulb, and overlying dura. The
operative technique has been previously described in detail
and is only briefly reviewed here.1,15 After the inferior
aspect of the nasal septum is removed to the level of unin-
volved margins, extended frontal and sphenoid sinusoto-
mies are performed. Next, the fovea ethmoidalis and sphe-
noid planum (anterior to the optic chiasm) are thinned and
removed to expose the overlying dura circumferentially,
which is subsequently incised. Dural margin specimens are
sent for frozen-section analysis prior to en bloc removal of
the inferior crista galli, perpendicular plate, cribriform plate,
olfactory bulb, and overlying dura.
yngology–Head and Neck Surgery, Toronto, Canada, September 17-20,
2006.
Reprint requests: Sandeep P. Dave, MD, University of Miami Hospital
and Clinics, 1475 NW 12th Avenue, Suite 4025 (D-1), Miami, FL 33136.
E-mail address: sdave@med.miami.edu.
Dave et al Surgical outcomes and safety of transnasal . . .
Recently, Batra et al2 presented a comparison between
CFR (n ⫽ 16) and TER (n ⫽ 9) for ASB tumors. Six
patients in the TER group underwent a purely endoscopic
resection, while three patients required an endoscopic-as-
sisted CFR to address obvious intracranial extension. Al-
though the cribriform plate was removed as the superior
margin in the six cases of purely endoscopic resection, it is
unclear whether the resection was performed en bloc and
whether the overlying dura was removed. Given the small
sample size, they observed no statistically significant dif-
ferences between groups. However, there were several in-
teresting trends favoring the TER group for operative time,
stay in the intensive care unit (ICU), major complications,
and mortality. They concluded that TER may offer less
functional morbidity with equal efficacy compared with
CFR and that TER was a rational option in select patients.
In the present series, we report 19 cases of TER for ASB
tumors. To date, this represents the largest series in the
literature of formal transnasal endoscopic resection of ASB
tumors without the need for open craniotomy. We have
included four of the five patients from the senior author’s
previous series.1 Of the four patients included, review of the
histopathology from one of the patients revealed that the
primary neoplasm was most likely a sinonasal undifferen-
tiated carcinoma (SNUC), not an olfactory neuroblastoma.
The one patient who was excluded from the present series
was a case of recurrent olfactory neuroblastoma, which
required a revision endoscopic resection that did not involve
the anterior skull base.
MATERIALS AND METHODS
After the study protocol was approved by the institutional
review board, a retrospective chart review was performed to
identify patients undergoing TER for ASB tumors between
September 1997 and June 2006 at the University of Miami/
Jackson Memorial Medical Center. Patient records were
evaluated for demographic data, clinical presentation, oper-
ative procedure, postoperative course, tumor staging, his-
topathological findings, immediate and delayed complica-
tions, rates of recurrence and metastasis, and mortality.
Olfactory neuroblastomas were staged according to the
Kadish staging system. All other malignant lesions were
staged according to the TNM staging system for nasal
cavity and ethmoid sinus malignancies. Preoperative imag-
ing included computed tomography (CT) and/or magnetic
resonance imaging (MRI).
Early in the study period, TER was considered for tu-
mors without significant intracranial extension and for pa-
tients of advanced age or with significant medical comor-
bidities in whom traditional CFR was believed to be too
high a risk. In later years, the indications for TER were
expanded to include younger and healthier patients, and
most ASB tumors. All ASB resections and reconstructions
were performed by a single surgeon. Image guidance was
921
not used for any of the cases, and neurosurgical support was
available at all times.
The extent of ASB resection was categorized into three
groups: bilateral, unilateral, and partial (Fig 1). Bilateral or
complete resection involved removal of the entire ASB,
including the crista galli, perpendicular plate, cribriform
plate, olfactory bulb, and overlying dura circumferentially.
When these structures were removed as a single specimen,
it was considered an en bloc resection. Unilateral resection
involved removal of the cribriform plate and olfactory bulb
unilaterally. When these structures were removed as a single
specimen with the adjacent dura and a portion of the crista
galli and perpendicular plate, it was considered an en bloc
resection. When these structures were removed piecemeal
or when the crista galli and/or perpendicular plate were
burred down from the side of the resection, it was consid-
ered a non– en bloc resection. All other limited ASB resec-
tions that involved only a segment of the fovea ethmoidalis
and overlying dura were considered partial resections, and
therefore non– en bloc resections. Kuhn et al’s13 resection of
an ASB fibrosarcoma would be considered a partial resec-
tion. For all bilateral and unilateral resections, the bony
fovea ethmoidalis and sphenoid planum were removed in a
piecemeal fashion to gain exposure to the overlying dura.
The endoscopic view of a representative bilateral ASB de-
fect is shown in Figure 2A.
The operative technique for transnasal endoscopic ASB
resection and reconstruction has been previously described
in detail.1,15 All reconstruction materials were soaked in
polymyxin “bug juice” antibiotic solution. Early in the
study period, we used lyophilized dura and mucosal grafts
to reconstruct the ASB defect. Currently, we use a single
sheet of acellular dermal allograft/Alloderm (LifeCell Cor-
poration, Branchburg, NJ), a layer of Gelfoam (Pharmacia,
Kalamazoo, MI), and Merocel (Medtronic-Xomed, Jack-
sonville, FL) tampons. The Merocel tampons were removed
within 5 days. The intraoperative view of a representative
Alloderm reconstruction is shown in Figure 2B. Prolonged
crusting secondary to atrophic rhinitis was defined as crust-
ing longer than six months after completion of radiation
therapy.
RESULTS
A summary of patient data is presented in Table 1.
Demographic Data/Clinical Presentation
Twenty consecutive patients underwent TER of ASB tu-
mors. Only one patient was excluded from the analysis
because he required a bifrontal craniotomy to clear the right
supraorbital dural margin. Of the remaining 19 patients (11
males, eight females) the mean age was 61.6 years (range
39-81 years). Significant medical comorbidities were
present in 11 patients (58%) as shown in Table 1. Nasal
airway obstruction (68%) was the most common presenting
922 Otolaryngology–Head and Neck Surgery, Vol 136, No 6, June 2007

Figure 1 Diagram depicting the minimal extent of resection for bilateral (A) and unilateral (B) endoscopic anterior skull base resections
in the coronal and sagittal (C) planes.

Figure 2 Intraoperative photographs demonstrating an anterior skull base defect after bilateral endoscopic resection (A) and reconstruc-
tion with a single sheet of Alloderm (B). The margins of resection include the orbital walls laterally (arrows), frontal sinus anteriorly (F),
and sphenoid sinus posteriorly (S).
Dave et al Surgical outcomes and safety of transnasal . . .
symptom, followed by facial pain or headache (53%), epi-
staxis (42%), visual disturbance (5%), and no symptoms
(5%).
Three patients had a planned 2-stage procedure in which
the approach to the ASB and diagnostic biopsies were
performed first, followed by a formal ASB resection at a
second operative setting after histopathological confirma-
tion. Four patients had a planned single-stage procedure.
The remaining 12 patients were referred after a prior partial
resection in which the diagnosis of an ASB neoplasm was
obtained.
Operative and Perioperative Data
The extent of resection included nine bilateral, six unilat-
eral, and four partial resections. One of the partial resections
was a revision for recurrent olfactory neuroblastoma after a
previous CFR and postoperative radiation therapy. An en
bloc resection was performed in 11 patients. The remaining
non– en bloc resections included four unilateral resections,
in which a portion of the specimen was removed piecemeal
or burred down with a drill, and four partial resections.
The reconstruction of the resulting ASB defects is shown
in Table 1. Nine defects (47%) were reconstructed with
Alloderm alone. Other reconstruction techniques in-
cluded the use of lyophilized dura and mucosal graft in
four patients (21%), alloderm and mucosal graft in three
patients (16%), mucosal graft alone in two patients
(11%), and Gelfoam alone in one patient (5%). There
were no postoperative CSF leaks.
The mean operative time was 245 minutes (range 153-
405 minutes). The mean blood loss was 985 ml (range
300-2400 ml). All but two patients received intraoperative
antibiotics, and all patients received systemic antibiotics
postoperatively while in the hospital. The average hospital
stay, which included the day of surgery, was 3.7 days (range
2-9 days). Only one patient required a period of observation
in the ICU, which lasted two days. No patients required a
lumbar drain or tracheotomy.
Tumor Characteristics
There were 17 malignant and two benign lesions. Olfactory
neuroblastoma was the most common pathology, occurring
in 10 patients (53%). One recurrent olfactory neuroblastoma
and two benign lesions were not staged. On the basis of the
Kadish staging system, there were five stage A (55%), two
stage B (22%), and two stage C (22%) olfactory neuroblas-
tomas. Of the remaining seven malignancies, there were two
T1 (29%), one T2 (14%), two T3 (29%), and two T4 (29%)
lesions. Three patients (patients 13, 14, and 17) had dural
involvement, and patient 7 (sarcomatous meningioma) dem-
onstrated intracranial involvement with an indentation of
the brain parenchyma. Although all margins were cleared by
intraoperative frozen-section analysis, two patients (patients
7 and 13) demonstrated close margins of resection on per-
manent histopathological examination. Neither of these pa-
tients has had a recurrence at 12 and 35 months postoper-
923
atively. All patients with malignant disease, excluding the
two with hemangiopericytoma, and one with recurrent olfac-
tory neuroblastoma who was previously radiated, received
postoperative radiation therapy. One patient with small cell
carcinoma also received postoperative chemotherapy.
Recurrence/Metastases and Mortality
The mean follow-up period was 34.3 months (range 3-105
months). As of the last follow-up visit, only one patient
(patient 4) had recurred locally. He underwent revision
endoscopic resection for a posteroinferior septal recurrence
at 52 months after his original TER. Despite an aggressive
revision resection, which included a completion septec-
tomy, removal of nasopharyngeal mucosa and musculature,
and burring of the rostrum and sphenopalatine area into the
pterygomaxillary space, diffuse microscopic disease was
present on virtually all frozen-section specimens. The pa-
tient decided against postoperative chemotherapy or further
radiation therapy to address his recurrence. Review of the
initial and revision resection specimens demonstrated sev-
eral skip lesions on histopathological examination. One
patient (patient 5) with recurrent olfactory neuroblastoma
developed regional metastases to the eyelid. Another patient
(patient 3) with HIV infection and SNUC subsequently
developed regional and distant metastases to the neck, tem-
poral bone, and lung. These were treated with modified neck
dissection, postoperative radiation therapy, and palliative
chemotherapy. The patient subsequently died at 24 months
postoperatively and represented the only mortality in the
series. The overall local control rate for all neoplasms was
94.7 percent and 94.1 percent for malignant disease. It
should be noted that the tumor control rate may be prema-
ture given the small sample size and limited follow-up.
Complications
Overall, there were 16 complications, which are summa-
rized in Table 2. Five intraoperative complications occurred
in four patients. Three patients had intraoperative bleeding
that required blood transfusion. Patient five, who underwent
a partial ASB resection for recurrent olfactory neuroblas-
toma, had a small unplanned CSF leak that was repaired
with Gelfoam. The same patient also developed an orbital
hematoma that required a lateral canthotomy and medial
orbital decompression. She did not have any permanent
visual sequelae.
Three immediate postoperative complications occurred
in three patients, including symptomatic anemia in two
patients (patients 2 and 9), who required blood transfusion.
Overall, the perioperative transfusion rate was 26.3 percent.
Patient 5 developed unexplained altered mental status,
which required a 2-day admission to the ICU. She promptly
improved without any permanent sequelae. There were no
perioperative mortalities.
Eight delayed postoperative complications occurred in
five patients. Two patients (patients 2 and 9) developed
epistaxis requiring endoscopic cauterization, one at one
924 Otolaryngology–Head and Neck Surgery, Vol 136, No 6, June 2007

Table 1
Patient summary

Patient no./age/gender/ OR time

comorbidity Pathology/stage Resection Reconstruction (min)

1/49/F/none OFN/stage A Non–en bloc, unilateral Lyophilized dura, MT 285

mucosa
2/63/M/CAD, CHF, DM OFN/stage B En bloc, bilateral Lyophilized dura, 405
MT mucosa
3/52/M/HIV infection SNUC/stage T3 En bloc, bilateral Lyophilized dura, 375
MT mucosa
4/76/M/CAD Adenoid cystic carcinoma/ Non–en bloc, partial Septal mucosa 190
stage T2
5/81/F/none Recurrent OFN Non–en bloc, partial Gelfoam 155

6/78/F/CAD OFN/stage A Non–en bloc, unilateral MT mucosa 195

7/70/M/IDDM Sarcomatous meningioma/ En bloc, bilateral Lyophilized dura, septal 315
stage T4a bone, MT mucosa
8/52/M/HCC OFN/stage A Non–en bloc, unilateral Alloderm, septal mucosa 265
9/73/F/none Hemangio-pericytoma/ En bloc, unilateral Alloderm, mucosal graft 270
stage T3
10/69/F/CAD, IDDM Hemangio-pericytoma/ Non–en bloc, partial Alloderm, mucosal graft 153
stage T1
11/39/F/none Benign osteoblastic Non–en bloc, partial Alloderm 178
neoplasm/stage n/a
12/73/M/none OFN/stage A En–bloc, unilateral Alloderm 258
13/56/M/CAD Small cell carcinoma/ En bloc, bilateral Alloderm 330
stage T4b
14/39/M/none OFN/stage C En bloc, bilateral Alloderm 396
15/79/F/IDDM Adenoid cystic carcinoma/ En bloc, bilateral Alloderm 169
stage T1
16/45/F/MS Hemangioepithilioma/ Non–en bloc, unilateral Alloderm 240
stage n/a
17/39/M/none OFN/stage C En bloc, bilateral Alloderm 175
18/79/M/Afib OFN/stage A En bloc, bilateral Alloderm 230
19/59/M/none OFN/stage B En bloc, bilateral Alloderm 280
OR, Operative; F/U, follow-up; CAD, coronary artery disease; CHF, congestive heart failure; DM, diabetes mellitus; HIV, human
immunodeficiency virus; IDDM, insulin-dependent diabetes mellitus; HCC, hepatitis C cirrhosis; MS, multiple sclerosis; Afib, atrial
fibrillation; OFN, olfactory neuroblastoma; MT, middle turbinate; XRT, radiation therapy; SNUC, sinonasal undifferentiated carci-
noma; ICU, intensive care unit; AMS, altered mental status; n/a, not applicable.

month and the other at 40 months postoperatively. Patient
15 presented with a small linear scar in her nasal vestibule,
presumably secondary to an intraoperative injury from en-
doscopic manipulation. Patients 3 and 7 developed atrophic
rhinitis and prolonged crusting, which were treated with
transnasal irrigation, and topical and oral antibiotics with
improvement. One patient (patient 2) partially extruded his
lyophilized dural graft at eight months postoperatively with-
out a CSF leak. Patient 7 developed a frontal lobe abscess
that required craniotomy and drainage, and subsequently
suffered radiation-induced loss of vision in his right eye.
DISCUSSION
Traditional CFR through an external approach has been the
gold standard for resection of ASB tumors.1,2 This approach
was originally applied to the treatment of sinonasal neo-
plasms by Smith et al16 in 1954, and the skin incisions and
bony cuts that were described by Ketcham in 1963 are still
used today. Proponents of this approach maintain that, de-
spite significant morbidity, traditional CFR allows for a true
en bloc oncological resection.1,2 Although in theory, a
piecemeal removal may increase the rate of local recurrence
through tumor seeding, this result has not been demon-
strated clinically.2,8,15 Other authors insist that a true en bloc
resection is rarely realized with traditional CFR given the
limited access to certain key anatomical areas, including the
sphenoid sinus, frontal recess, nasion, and orbital apex.
Furthermore, piecemeal CFR does not appear to adversely
affect survival.1,2,8,15,17,18 More recently, the need for uni-
versal resection of the entire ASB has been called into
question, and it is possible that, in select cases, unilateral
and partial resections may be advisable.
The morbidity and mortality associated with traditional
CFR is quite high. The overall major complication rate is
Dave et al Surgical outcomes and safety of transnasal . . . 925

Table 1
(continued)

Blood Hospital Adjuvant Positive margins/ F/U

loss (mL) stay (d) Complications therapy recurrence Metastasis (mo)

715 2 None XRT No/no No 105

1100 5 Transfusion, graft extrusion, epistaxis XRT No/no No 104

1500 3 Transfusion, atrophic rhinitis XRT No/no Neck, temporal 24

bone, lung
500 2 None XRT No/yes No 55

1000 92 (ICU) Intraop CSF leak, orbital hematoma, No No/no Eyelid 75

transient AMS
500 2 None XRT No/no No 18
2400 7 Transfusion, frontal lobe abscess, XRT No/no No 12
atrophic rhinitis, XRT visual loss
800 2 None XRT No/no No 55
900 5 Transfusion, epistaxis No No/no No 44

300 4 None No No/no No 44

450 2 None No No/no No 15

2000 5 Transfusion XRT No/no No 26

1000 3 None XRT chemo No/no No 35

1500 3 None XRT No/no No 10

600 4 Nasal vestibule scar XRT No/no No 10

850 3 None No No/no No 7

700 4 None XRT No/no No 5

1500 3 None XRT No/no No 3
400 4 None XRT No/no No 4

reported to be as high as 30 to 50 percent,3,4 and includes
significant intracranial, orbital, infectious, cosmetic, and
systemic morbidities.1,5 Perioperative mortality has been
reported in 0 to 13 percent of cases.2 Therefore, a less
invasive but equally effective approach would be desirable.
In the 1990s, endoscopic-assisted CFR, in which the ASB is
approached via a bifrontal craniotomy from above and endo-
scopically from below, was described.1,6-8 More recently, with
advances in endoscopic technology and surgical experience,
TER for ASB tumors, which avoids the need for open
craniotomy, has become more prevalent.1,2,9-15 Advocates
of the transnasal endoscopic method claim that the superior
visualization with angled endoscopes and improved instru-
mentation allows for an oncologically sound resection with
equivocal results.1,2 Other stated advantages include avoid-
ance of craniotomy, facial, gingival, and bicoronal inci-
sions, extensive facial osteotomies, lumbar drains, trache-
otomy, and frontal lobe retraction.1,2,5,6,8 TER also allows
for better preservation of uninvolved structures and thus
limits subsequent functional morbidity compared with
CFR.2,15 Some potential advantages include decreased op-
erative time, reduced anesthetic risk, shorter hospital stay,
less postoperative pain, and fewer complications.
Regardless of the approach, complete tumor extirpation
is essential. Local recurrence, poor outcomes, and decreased
survival are all associated with positive surgical margins.19
In our series, there were no positive margins. Close margins
of resection were demonstrated on permanent histopathol-
gical examination in two patients, and to date neither has
recurred. One patient with adenoid cystic carcinoma did
recur, which was most likely secondary to skip lesions that
were demonstrated on both the initial and revision resection
specimens.
The ability to completely remove the tumor by TER must
be assessed by thorough preoperative examination and re-
view of imaging. Appropriate patient selection is key. If
926 Otolaryngology–Head and Neck Surgery, Vol 136, No 6, June 2007

Table 2
and TER. For the purposes of this study, we chose to
Summary of complications consider these effects as a complication. By doing so, we
emphasized them as an outcome, because we believe they
Patient complications No. of pts may be less frequent following TER given the less extensive
resection.
Intraoperative
Blood transfusion 3 Interestingly, all 16 complications occurred in only seven
Small unplanned CSF leak 1 patients. Single complications developed in two patients
Orbital hematoma 1 (patients 12 and 15) with early stage tumors. Multiple com-
Total 5 in 4 patients
plications developed in three patients with T3 or T4 tumors
Immediate postoperative
Blood transfusion 2 (patients 3, 7, and 9), one patient with a recurrent lesion
Transient AMS 1 (patient 5), and one patient with a Kadish stage B neoplasm
Total 3 in 3 patients (patient 2). Furthermore, two major complications occurred
Delayed postoperative in a single patient with a T4a lesion (patient 7). These
Epistaxis 2
Atrophic rhinitis/crusting 2 findings suggest that certain patient factors—particularly
Nasal vestibule scar 1 advanced tumor stage—were associated with increased
Extrusion of graft 1 perioperative morbidity.
Frontal lobe abscess 1 Because adjuvant radiation therapy is not without mor-
XRT visual loss (unilateral) 1
Total 8 in 5 patients bidity, its role after TER must be elucidated. Atrophic
rhinitis, blindness, frontal lobe necrosis, and radiation-
Pts, Patients; CSF, cerebrospinal fluid; AMS, altered men-
tal status; XRT, radiation. induced malignancies are only some of the potential com-
plications. In a recent review, Bentz et al20 suggested that,
for ASB neoplasms treated by traditional CFR, postopera-
tive radiation therapy may be necessary only for tumors that
complete removal cannot be achieved, other approaches demonstrate high-grade pathology, positive margins, large
must be considered. If it is realized intraoperatively that volume of disease, or extensive local invasion (ie, dura).
surgical margins cannot be cleared by TER alone, the sur- Therefore, in select cases, traditional CFR may preclude the
geon should be prepared to either stage the procedure for a need for postoperative radiation, which is currently recom-
later date or convert to an open approach. Neurosurgical mended for all our patients in whom TER is performed for
support must be available in case an open craniotomy is malignant disease.
necessary, as was needed for the one patient who was In summary, the overall morbidity and mortality as-
excluded from this review. An endoscopic-assisted CFR is sociated with TER appear to be less than that with tra-
an option to address significant intracranial extension. For ditional CFR. There was only one significant intracranial
significant inferior extension to the floor of the nose, ante- and one significant intraorbital complication, neither of
rior extension that involves the facial soft tissues, and lateral which resulted in permanent disability. The major com-
extension to the maxillary sinus, orbit, pterygomaxillary plication rate directly related to surgery was 11 percent.
space, or infratemporal fossa, a traditional CFR is usually TER for ASB tumors requires a high degree of experi-
indicated if endoscopic resection is not possible.2,7 Endo- ence. Although not used in this series, image guidance
scopes and endoscopic instrumentation can still be used may be used, but is not necessary for most cases. Con-
with a traditional CFR to improve visualization and access
version to an external approach may be necessary; there-
to key anatomical areas.8 For tumors that are considered
fore, neurosurgical support must be available. Patients
unresectable, TER may play a role in palliation.2
with significant comorbidities and advanced age, who
Overall, 16 complications occurred in the current series.
might not otherwise tolerate an extensive CFR, appear to
Of these, we would consider only three to be major com-
be ideal candidates. In fact, our experience with TER for
plications. Two of these, the orbital hematoma and frontal
lobe abscess, were directly related to the operative proce- ASB tumors evolved from a need to treat these patients in
dure. Neither patient suffered any permanent sequelae. The whom traditional CFR was considered too high a risk.
other complication, unilateral radiation-induced loss of vi- These patients were actually referred by head and neck
sion, was a result of postoperative radiation therapy. Two oncology surgeons or neurosurgeons for a less invasive
patients developed atrophic rhinitis and prolonged crusting, endoscopic option. Although more than 30 percent of the
which was attributed to a combination of extensive mucosal tumors in this series were Kadish stage C or TNM stage
resection and radiation therapy. Both of these patients had T3/T4, less advanced tumors appear to be more amenable
advanced lesions (T3 and T4a). It should be noted that to TER and result in less postoperative morbidity. Fur-
atrophic rhinitis and prolonged crusting are more accurately thermore, unilateral and partial resections may be advis-
classified as a consequence of surgery and radiation therapy, able in certain cases. The current analysis demonstrates
rather than as a complication. In theory, both effects would that, in a select group of patients and neoplasms, the
be expected to occur at similar rates after traditional CFR short-term local control (95%) appears to be excellent.
Dave et al Surgical outcomes and safety of transnasal . . .
CONCLUSIONS
In this preliminary review, TER for ASB tumors appears to
be safe. A larger, multi-institutional series with longer fol-
low-up and direct comparison to CFR using patient- and
tumor stage matched data is warranted.
The authors thank Brian P. Dunham, MD, for creating the
original illustrations in the manuscript.
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