It may seem strange to suggest that techniques used to take out brain tumors should be used for routine sinus surgery, but the relationship becomes clear when the location of the sinuses is considered. As shown in the image below, most of the sinuses (the ethmoid sinuses, frontal sinuses, and sphenoid sinus) are located just below the “brain case” which is also called the skull base or cranial base.
Employ Skull Base Surgery Techniques
Skull and brain case from the side
Purple areas are the sinuses just below the brain case
In fact, the roof of these sinuses is actually formed by the brain case itself. As a result, most of the serious complications that can arise from sinus surgery arise from accidental entry into the brain case (intracranial) when trying to open or clear disease from the sinuses below. If the brain case is entered bleeding can occur that can be life threatening (intracranial hemorrhage). Though rare, this is a known complication of minimally invasive, endonasal, endoscopic sinus surgery. Further, an entry into the brain case can cause a cerebrospinal fluid leak.
The brain floats in fluid that looks just like water and is called the cerebrospinal fluid (CSF). Should a CSF leak occur during sinus surgery, it must be recognized and repaired as both air and bacteria can enter the brain case causing meningitis. Skull base surgeons intentionally enter the brain case through the sinuses to take out tumors, and as a result have extensive experience in repairing CSF leaks. For most ENT surgeons, such a leak would only occur once in very great while, and they frequently do not have the skills to repair the CSF leak at the time of injury. As a result, it is important to select a surgeon with “skull base surgery” experience, particularly for more complicated sinus surgeries. Such cases include those patients who have been operated on before and have persistent or recurrent sinus disease.
The other areas of concern are the eye sockets, eyes, and the nerve that leads from the eye (optic nerve). These critical structures form, at least in part, the outer walls of all of the sinuses. Further, the fine nerves that extend down from the brain through the skull base give rise to your sense of smell. If they are damaged, a patient’s sense of smell can be diminished or destroyed, and it will not recover. As a result, if a surgeon gets “off target”, permanent injury to a patient’s vision (blindness) and sense of smell (anosmia) can occur.
Dr. Costantino is one of the founding members of the North American Skull Base Society, and he performs surgeries that intentionally result in CSF leaks, and expose the contents of the eye sockets and the optic nerve routinely. As a result, he is familiar with these critical structures, operates around them routinely, and has substantial experience in preventing or dealing with complications. As a benchmark, it is estimated that Dr. Costantino has participated in the endoscopic, trans-nasal removal of several thousand pituitary tumors to this point in his career. He has also repaired hundreds of CSF leaks that intentionally resulted from those surgeries. He has also been consulted routinely when other surgeons cause such complications to fix the problem.
The use of an endoscope through the nostrils to visualize the undersurface of the brain case.