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Transfacial approaches to the skull base: the early contributions of harvey cushing.

ABSTRACT: In this report, we review Dr. Cushing's early surgical cases at the Johns Hopkins Hospital, revealing details of his early use of craniofacial approaches for malignant pathology of the skull base. Following Institutional Review Board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912, which included three patients who underwent surgical treatment of lesions involving the skull base through craniofacial approaches: two adults and one child (range 3 to 43 years). The main outcome measures were length of stay and condition recorded at the time of discharge. The indications for surgery included osteochondroma of the sphenoid sinus, sarcoma of the maxillary sinus and middle fossa, and osteoma of the frontal sinus. The mean length of stay was 24.5 days (range 7 to 45 days). Cushing employed craniofacial approaches for malignant pathology nearly 40 years before such techniques became widely used. He practiced the fundamentals of skull base surgery, including preferential removal of bone to achieving adequate exposure for resection. In addition, Cushing clearly understood the importance of proximal vascular control in approaching lesions with complex vascular involvement.

SUBMITTER: Pendleton C

PROVIDER: S-EPMC3312120 | biostudies-other | 2011 Jul

REPOSITORIES: biostudies-other

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Harvey Cushing's Early Operative Treatment of Skull Base Fractures.

Project description:Objectives To review Dr. Harvey Cushing's early surgical cases at the Johns Hopkins Hospital, revealing details of his operative approaches to fractures of the skull base. Design Following institutional review board approval and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files. Setting The Johns Hopkins Hospital, 1896 to 1912. Participants A total of 24 patients underwent operative treatment for suspected fractures of the skull base. Main Outcome Measures The main outcome measure was operative approach, postoperative mortality, and condition recorded at the time of discharge. Results Overall, 23 patients underwent operative treatment for suspected skull base fractures. The mechanisms of injury were known for 22 patients and included work-related injuries (41%), falls (23%), vehicle injuries (32%), and other trauma (5%). One patient had no mechanism of injury specified in the file. The outcome at the time of discharge from the hospital was "well" or "improved" in 12 patients (52%). The remaining 11 patients died during their admission. Conclusions Although Cushing's experience with selected skull base pathology has been previously reported, the breadth of his contributions to operative approaches to the skull base has been neglected.

| S-EPMC3912145 | biostudies-other

Harvey Cushing's Approaches to Tumors in His Early Career: From the Skull Base to the Cranial Vault.

Project description:In this report, we review Dr. Cushing's early surgical cases at the Johns Hopkins Hospital, revealing details of his early operative approaches to tumors of the skull base and cranial vault. Following Institutional Review Board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912. Participants included four adult patients and one child who underwent surgical resection of bony tumors of the skull base and the cranial vault. The main outcome measures were operative approach and condition recorded at the time of discharge. The indications for surgery included unspecified malignant tumor of the basal meninges and temporal bone, basal cell carcinoma, osteoma of the posterior skull base, and osteomas of the frontal and parietofrontal cranial vault. While Cushing's experience with selected skull base pathology has been previously reported, the breadth of his contributions to operative approaches to the skull base has been neglected.

| S-EPMC3312114 | biostudies-other

The pursuit of a cholesteatoma by harvey cushing: staged approach to a complex skull base tumor.

Project description:Objective The evolution of neurosurgical techniques during Harvey Cushing's practice was immense. The authors illustrate this evolution using archived historical records from Harvey Cushing. Setting Historical patient records retained by the Cushing Center at Yale University Department of Neurosurgery. Design The authors present the case of one of Cushing's patients with a cholesteatoma. Results Cushing's surgical treatment of a cholesteatoma extending into the skull base is an example of his meticulous documentation and accelerated surgical techniques. Conclusions This case demonstrates how neurosurgical techniques advanced in the management of complex skull base tumors via a staged approach through the middle and posterior fossae at a time long before the development of modern skull base surgery.

| S-EPMC4176541 | biostudies-other

Harvey Cushing Treated the First Known Patient With Carney Complex.

Project description:Context:Carney complex (CNC) is a syndrome characterized by hyperplasia of endocrine organs and may present with clinical features of Cushing syndrome and acromegaly due to functional adrenal and pituitary gland tumors. CNC has been linked to mutations in the regulatory subunit of protein kinase A type I-alpha (PRKAR1A) gene. Design:Tissue samples were taken from the hypothalamus or thalamus or tumors of patients with pituitary adenomas seen and operated on by neurosurgeon Harvey Cushing between 1913 and 1932. Following DNA extraction, sequencing for genes of interest was attempted, including PRKAR1A, AIP, USP8, GNAS1, and GPR101, to explore the possibility that these mutations associated with acromegaly, CNC, and Cushing syndrome have been conserved over time. Results:We report a patient described by Dr. Cushing in 1914 with a clinical presentation and postmortem findings suggestive of CNC. Genetic sequencing of the hypothalamus and pituitary adenoma revealed a germline heterozygous p.Arg74His mutation in the PRKAR1A gene, a codon previously described as mutated in CNC, but with a novel amino acid change. Conclusions:This patient is, to our knowledge, the first molecularly confirmed individual with CNC. This case demonstrates the power of modern genetics in studying archived tissues and the importance of recording detailed clinical notes in the diagnosis of disease.

| S-EPMC5686675 | biostudies-literature

Minimally invasive surgery of the anterior skull base: transorbital approaches.

Project description:Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach.

| S-EPMC4940979 | biostudies-other

Swing technique for middle turbinate preservation in expanded endonasal skull base approaches.

Project description:Endoscopic endonasal approaches to the middle fossa and orbital apex have traditionally included resection of the middle turbinate to improve visualization and operating space. The aim of this publication is to demonstrate a surgical technique that affords similar visualization and space but preserves the middle turbinate. We describe a technical modification that allows for conservation of the middle turbinate and describe an illustrative case. As current surgical techniques evolve towards progressively less morbidity, preservation of anatomic structures such as the middle turbinate will be pursued. In the case described, middle turbinate preservation did not negatively affect access or visualization and did not appear to alter postoperative wound healing. With middle turbinate preservation, the principle function of airflow conditioning and potential neural regeneration are maintained.

| S-EPMC4783157 | biostudies-literature

Human skull base chordoma LC-MSMS

Project description:The prognostic factors of skull base chordoma associated with outcomes of patients after surgical resection remain poorly defined. This project aimed to identify a novel prognostic factor for patients with skull base chordoma. Using a proteomics approach, we screened tumor biomarkersthat upregulated in the rapid-recurrence group of chordoma, narrowed down by bioinformatics analysis, and finally potential biomarker was chosen for validation by immunohistochemistry using tissue microarray.

2021-11-03 | PXD025894 | Pride

Transorbital endoscopic approaches to the skull base: a systematic literature review and anatomical description.

Project description:Transorbital endoscopic approaches are increasing in popularity as they provide corridors to reach various areas of the ventral skull base through the orbit. They can be used either alone or in combination with different approaches when dealing with the pathologies of the skull base. The objective of the current study is to evaluate the surgical anatomy of transorbital endoscopic approaches by cadaver dissections as well as providing objective clinical data on their actual employment and morbidity through a systematic review of the current literature. Four cadaveric specimens were dissected, and step-by-step dissection of each endoscopic transorbital approach was performed to identify the main anatomic landmarks and corridors. A systematic review with pooled analysis of the current literature from January 2000 to April 2020 was performed and the related studies were analyzed. Main anatomical landmarks are presented based on the anatomical study and systematic review of the literature. With emphasis on the specific transorbital approach used, indications, surgical technique, and complications are reviewed through the systematic review of 42 studies (19 in vivo and 23 anatomical dissections) including 193 patients. In conclusion, transorbital endoscopic approaches are promising and appear as feasible techniques for the surgical treatment of skull base lesions. Surgical anatomy of transorbital endoscopic approaches can be mastered through knowledge of a number of anatomical landmarks. Based on data available in the literature, transorbital endoscopic approaches represent an important complementary that should be included in the armamentarium of a skull base team.

| S-EPMC8490260 | biostudies-literature

IMPROVED PRESERVATION OF FACIAL NERVE IN TRANSTEMPORAL APPROACHES TO THE SKULL BASE.

Project description:Surgery of the skull base has evolved over the past 100 years. The importance of combined otorhinological and neurosurgical approach in the management of lesions of the skull base has been realised in recent years. Through this strategy, lesions which were once thought unresectable are being removed completely with reduction in mortality. However, the morbidity due to facial palsy in lateral skull base surgery is common. To avoid this, intraoperative facial nerve monitoring was introduced in the late 70's and has been refined to such a point that it is now possible to safely predict the recovery of the temporary facial paralysis after lateral skull base surgery. The present study which was carried out in the Armed Forces for the first time has evaluated this by comparing 5 patients who underwent this surgery without intraoperative facial nerve monitoring with 5 patients who were operated with intraoperative facial nerve monitoring. The results have proved the efficacy of this tool in reducing the severity and duration of facial palsy after this surgery.

| S-EPMC5531971 | biostudies-other

Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review.

Project description:PurposePostoperative cerebrospinal fluid rhinorrhoea (CSFR) remains a frequent complication of endonasal approaches to pituitary and skull base tumours. Watertight skull base reconstruction is important in preventing CSFR. We sought to systematically review the current literature of available skull base repair techniques.MethodsPubmed and Embase databases were searched for studies (2000-2020) that (a) reported on the endonasal resection of pituitary and skull base tumours, (b) focussed on skull base repair techniques and/or postoperative CSFR risk factors, and (c) included CSFR data. Roles, advantages and disadvantages of each repair method were detailed. Random-effects meta-analyses were performed where possible.Results193 studies were included. Repair methods were categorised based on function and anatomical level. There was absolute heterogeneity in repair methods used, with no independent studies sharing the same repair protocol. Techniques most commonly used for low CSFR risk cases were fat grafts, fascia lata grafts and synthetic grafts. For cases with higher CSFR risk, multilayer regimes were utilized with vascularized flaps, gasket sealing and lumbar drains. Lumbar drain use for high CSFR risk cases was supported by a randomised study (Oxford CEBM: Grade B recommendation), but otherwise there was limited high-level evidence. Pooled CSFR incidence by approach was 3.7% (CI 3-4.5%) for transsphenoidal, 9% (CI 7.2-11.3%) for expanded endonasal, and 5.3% (CI 3.4-7%) for studies describing both. Further meaningful meta-analyses of repair methods were not performed due to significant repair protocol heterogeneity.ConclusionsModern reconstructive protocols are heterogeneous and there is limited evidence to suggest the optimal repair technique after pituitary and skull base tumour resection. Further studies are needed to guide practice.

| S-EPMC8416859 | biostudies-literature

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