Endoscopic Transnasal Anatomy of the Skull Base and Adjacent Areas: A Lab Dissection and Radiological Atlas

Review by G Kenyon
Harpenden, UK

The advent of rigid endoscopes and the development of instrumentation, allied with, as the authors of this book acknowledge, the leadership of surgical giants such as Wolfgang Draf and Heinz Stammberger, have all acted to transform surgery of the nose and paranasal sinuses. The onward march of such surgery has been relentless, and this magnificent book reflects the logical extension of the pioneering initial concepts to include areas that were previously only accessible surgically, using an open approach.

The majority of the contributors to this book are from the Otolaryngology Department at the University of Brescia, but there are also substantial contributions from neurosurgeons, radiologists and anatomists, and some of these emanate from other centres, particularly Vienna. The book sets out to create an endoscopic atlas of the surgical anatomy of the skull base and to impart an underlying philosophy as to the approaches required, as well as providing a step-by-step guide to the techniques to be used. As otolaryngologists, we are used to working to open the paranasal sinuses to exenterate benign disease. This book moves a long way from that and outlines procedures that would be most likely applicable to removal of much rarer pathologies including tumours, most of which would traditionally be treated by neurosurgeons or, given the reach of the approaches outlined, head and neck surgeons.

The initial chapters in the book expound the classification of the approaches used, and then move on to develop the concept of different ‘corridors’, which are opened and which act to access pathology. These are considered as being those pathways that are developed to keep critical neurovascular structures at the periphery of the dissection. The book then details the variety of such approaches available and concentrates initially on those that are generated in the sagittal plane, using the sphenoid as a focal point. By identifying the optic nerves and internal carotid arteries, it outlines dissections in the same plane that can be utilised to access pathology in a variety of specific areas lying between the posterior plate of the frontal sinus anteriorly and the upper cervical vertebrae to C2 posteriorly. Conceptually, these approaches are then overlaid by three paramedian areas in the coronal plane. The most anterior lies lateral to the internal carotid and provides access to the anterior cranial fossa and orbits, the middle is envisaged as including the parasellar region and the middle cranial fossa, and the most posterior accesses the posterior cranial fossa and adjacent structures. These are detailed as ‘mod- ules’, and it is explained that these will necessarily overlap, and that they will need to be married and variously combined depending on clinical need.

Each dissection is allocated a specific chapter and these form 19 of the remaining 24 chapters included in the book. Each starts with a short and well referenced introductory account, and includes, typically, a labelled diagram or dissection that illustrates the region being considered. This is followed by radiological imaging of the same area and then by pages of very high quality, endoscopically acquired pictures, each of which is annotated with a short piece of explanatory text. In each chapter there is also an accompanying table outlining the nasal and/or skull base phases of each procedure.

The whole atlas is replete with page after page of very high quality images, and the philosophy and the methodologies utilised in each approach are crystal clear. The accompanying narrative provides a didactic approach as to what exactly should be done, and, in many instances, the instruments that should be used are shown. As expected, there is no account of detailed pathology, and no account of either peri-operative care or of outcomes. These matters are not within the book’s remit. Instead, the book concentrates solely on how such surgery can be performed and the anatomy that must be respected. In that, it succeeds magnificently. The exposition and presentation are brilliant.

This is clearly a book for experienced specialist nasal endoscopic surgeons working in a team with neurosurgeons and expert radiologists in a tertiary centre. It is not a book for ordinary mortals. Anyone gifted enough and fortunate enough to be working within or developing such a team will find that reading this book significantly adds to their knowledge base. They should buy it immediately and consult it frequently.

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