Session 2: Skull base disease

Transnasal endoscopic orbital surgery is a nascient field incorporating the multi-disciplinary expertise of rhinologic and ophthalmic plastic surgeons to treat a variety of orbital tumors and disorders. In this lecture, we will describe the CHEER classification system which provides guidance to surgeons as to the accessibility of orbital locales from an endonasal perspective. We will also present a series of surgical videos highlighting salient considerations in a variety of diagnoses and orbital locations.

The holistic surgical management of sinonasal malignant disease is best considered as a triangle of patient, surgical and disease factors. Patient factors include patient preferences and wishes, as well as medical comorbidities. Surgeon factors include expertise and experience and choice of technique. The disease itself determines treatment choice through its location, spread and cell type.These surgical approaches may be classified as open: rhinectomy, rhinotomy, midfacial degloving and craniofacial resection; and endoscopic - " piecemeal disassembly" resections. All of these interventions should take place within the setting of a multi-disciplinary team approach in a specialist centre with access to appropriate radio- and chemotherapeutic options.

Raj Bhalla, ENT rhinologist, and Omar Pathmanaban, neurosurgeon, from Manchester describe their experience of collaborative working to treat diseases of the skull base and orbital apices. They discuss the endoscopic corridors that they use and applications for their surgery, particularly for pathologies in and around the chiasm and optic sheaths. They discuss advantages of the endoscopic approach, but also scenarios where it is less appropriate. Also their tips on how to set up such a specialised service.

This talk will briefly describe the history of recent reconstructive advances and how they have revolutionised the treatment of head and neck cancer and skull-base disease. It will focus on the late 20th century from the 1970s onwards when surgeons studied fresh cadavers to identify the blood supply of skin, muscle and bone tissue that could be removed from one part of the body and transplanted to another part of the body without causing undue harm at the donor site. It will list the advances in radiology that have aided diagnosis and treatment planning and the advances in anaesthesia which have enabled surgeons to substitute one long operation for many operations extended over months or years. And it will list the advances in surgical equipment particularly related to microsurgery that have facilitated this reconstructive revolution of microvascular free flap surgery. Several examples will be used to show how large parts of the face and skull base can be removed or lost through trauma but reconstructed to a point where the patient can have confidence that the brain will be separated from the face, so not susceptible to infection, and facial appearance can be restored to a point where the patient can resume relatively normal life. These examples will also show the limitations of these advances in restoring special structures and facial expression. Sometimes, the aim of surgery is not to cure the patient of disease but to prolong good quality life. The planning of this involves strong partnership with the patient and the family to ensure the expectations of the patient match those of the surgeon and the ability of the surgeon to deliver. The brings in the concept of surgical palliation of disease.