Head and neck cancer and skull base surgeon Nyall London describes the case of a patient who presented with a nasal mass that was determined to be human papillomavirus (HPV) positive sinonasal squamous cell carcinoma. The tumor was near her brain and other important nerves in her sinonasal cavity and skull base and was able to be endoscopically removed through the nostrils. The patient required adjuvant chemotherapy and radiation and is doing well 18 months after surgery.
Mhm. Hello. My name is Neil London. I'm an assistant professor of otolaryngology at johns Hopkins. Within the division of rhinology and skull base surgery, as well as the division of head neck cancer surgery. My background area of training includes both endoscopic and open surgical approaches for sino nasal malignancies and skull base tumors. The patient we are presenting today was a 58 year old female who is referred to Johns Hopkins Otolaryngology clinic with difficulty breathing through her nose, pressure in her face and a mild loss of sense of Smell. These non specific symptoms are very common way for these patients to present. She was seen by a JohNS Hopkins sinologist who perform nasal endoscopy identified a nasal mass performed biopsy in clinic and the patient was diagnosed with sino nasal squamous cell carcinoma. She underwent a high resolution CT and MRI scan of her sinuses in the skull base and was found to have an extensive sino nasal tumor near her brain. Another important nerves in her son, the nasal cavity and skull base. She was referred to me for evaluation of surgical options and she was seen by the members of our multidisciplinary team, including radiation and medical oncology. I presented her at our multidisciplinary tumor board where we reviewed her case and determined that our team recommended surgical resection of the tumor. The skull base surgery team reviewed her case and felt that her tumor was amenable to a purely endoscopic approach, meaning that we could completely remove her tumor through her nostrils without any incisions on her face here are the preoperative MRI images demonstrating the extent of the tumor from the skull base down to the level of the nasopharynx Preoperative cT scan images demonstrated concerning ostojic bone around the video nerve and V. Two of the trigeminal nerve. New Zealand Oscar P. Demonstrated what the appearance of the tumor looks like and the tumor was found to extend to the level of the nasopharynx indicating a nasal for injecting me would be needed. The tumor also extended up to the anterior skull base and the curb, a form indicating that later we would need to perform an anterior skull base reception. We started with an endoscopic trans steroid approach including drilling of the media to avoid plate and bone of the terra good wedge. The video nerve was identified and transected in the contents of the terrible palatine fossil were lateral. Ized a high speed drill was used to drill the bone surrounding the video nerve in a negative margin of the video nerve wasn't obtained. Additional drilling of bone around v. two was then performed with a high speed drill and the station tube was mobilized and an easel. Fair injecting me was performed. We then turned our attention to the anterior skull waster section and using angled endoscopy first opened the frontal sinuses, followed by removing removing the bone of the anterior skull base with a caress and run your here. My neurosurgery colleague dr. Gary Galya is opening the dura of the interior skull base and cutting the fox Further dissection is performed identifying the olfactory nerve and you can see the frontal lobe behind the pledge it A negative margin was obtained at the level of the olfactory nerve and here's what the final resection cavity looks like, including the nasal cavity. With preservation of the descending palatine nerve, V. Two and performing an endoscopic nasal fair injected me. We then turned our attention to the reconstruction including an inlaid with the origin followed by additional reconstruction and an overlay with allied ERM. The reconstruction was then supported with a mirror cell sponge. During the healing phase here's the post operative cT scan images demonstrating the resection cavity including removal of the bone near the video nerve and V. Two of the trigeminal nerve. Although negative surgical margins were obtained through this endoscopic approach. Given the extent of the tumor, the patient underwent adjuvant chemotherapy and radiation at johns Hopkins. She continues to undergo regular follow up visits and imaging studies and is doing well 18 months after surgery with no evidence of disease spread or recurrence. No
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