Die transnasale Route zur Schädelbasis. Von der Nasennebenhöhlenchirurgie zur Schädelbasischirurgie

Zusammenfassung

Die Indikationen zur Durchführung endonasal endoskopischer Operationsverfahren bei Erkrankungen der Schädelbasis und ihrer angrenzenden Strukturen haben sich in den letzten Jahrzehnten deutlich erweitert. Die Ursachen hierfür liegen nicht nur in verbesserten technischen Möglichkeiten, wie der intraoperativen Navigation, der Entwicklung spezialisierter Instrumente und der Erarbeitung detaillierter anatomischer Studien aus der endoskopischen Perspektive, sondern auch wesentlich in der zunehmenden Erfahrung mit endoskopischen Operationen der Schädelbasis in multidisziplinären Zentren. Endoskopisch endonasale Verfahren ermöglichen auch zu tiefliegenden Läsionen neue Zugangswege, die sich durch geringere Manipulation an neurovaskulären Strukturen und am Hirnparenchym auszeichnen und dennoch eine verbesserte Visualisierung gestatten. Sie reduzieren das Zugangstrauma, vermeiden äußere Schnitte und verringern die operationsbedingte Morbidität. Die endoskopisch endonasalen Methoden zum Verschluss von kleinen und großen Schädelbasisdefekten sind erwiesenermaßen gute Verfahren mit einer hohen Erfolgsquote, die besser als bei Kraniotomien ist. Die Entwicklung neuer lokaler und regionaler, gefäßgestielter Transplantate wie des Hadad-Lappens hat hierzu beigetragen. Diese Rekonstruktionstechniken werden auch bei Tumoroperationen in diesen Regionen erfolgreich eingesetzt. Die Systematik der erweiterten endonasalen Zugänge wird in diesem Referat detailliert dargestellt. Hierdurch sind Läsionen und Tumoren der vorderen, mittleren und teilweise auch hinteren Schädelbasis erreichbar. Um diese komplexen Eingriffe erfolgreich durchzuführen, sind eine enge interdisziplinäre Zusammenarbeit sowie die kontinuierliche Weiterbildung und das Training aller Beteiligten unbedingt erforderlich.

Abstract

The Transnasal Approach to the Skull Base. From Sinus Surgery to Skull Base Surgery

The indications for endonasal endoscopic approaches to diseases of the skull base and its adjacent structures have expanded considerably during the last decades. This is not only due to improved technical possibilities such as intraoperative navigation, the development of specialized instruments, and the compilation of anatomical studies from the endoscopic perspective but also related to the accumulating experience with endoscopic procedures of the skull base by multidisciplinary centers. Endoscopic endonasal operations permit new approaches to deeply seated lesions and are characterized by a reduced manipulation of neurovascular structures and brain parenchyma while at the same time providing improved visualization. They reduce the trauma caused by the approach, avoid skin incisions and minimize the surgical morbidity. Transnasal endoscopic procedures for the closure of small and large skull base defects have proven to be reliable and more successful than operations with craniotomies. The development of new local and regional vascularized flaps like the Hadad-flap have contributed to this. These reconstructive techniques are furthermore effectively utilized in tumor surgery in this region. This review delineates the classification of expanded endonasal approaches in detail. They provide access to lesions of the anterior, middle and partly also to the posterior cranial fossa. Successful management of these complex procedures requires a close interdisciplinary collaboration as well as continuous education and training of all team members.

Schlüsselwörter

endoskopische Schädelbasischirurgie - Schädelbasisdefekt - Schädelbasistumor - Rhinoliquorrhoe - Rekonstruktion

Key words

endoscopic skull base surgery - skull base defect - skull base tumour - rhinoliquorrhea - reconstruction

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