Center for Skull Base Surgery: Summer 2017

Pittsburgh CREATES the Future of Surgery Pittsburgh CREATES = Collaborative Research, Education, And Technology Enhancement in Surgery It is often said that “too many cooks spoil the broth” but if you’re trying to whip up something a little more complex, it’s better to have all the cooks in the kitchen together!

That is what Pittsburgh CREATES does. It brings together surgeons, engineers, and medical device companies to create an environment where new technologies can be imagined and developed. The Center’s skull base surgeons are currently pursuing multiple inventions in collaboration with engineers from the University of Pittsburgh Swanson School of Engineering, start-up companies in Pittsburgh, and global medical device companies. Here are a few examples.

Nitinol suction dissectors

Nitinol surgical instruments. Surgical instruments are designed to be “one size fits all” and often do not accommodate the unique anatomy of each patient. Working with a research institute in Germany, our team has developed bendable suction dissectors made from Nitinol. Nitinol is a shape memory alloy that is temperature dependent. The surgeon can shape the instrument during surgery to reach the tumor. When the instrument is sterilized at high temperature following surgery, it returns to its original shape.

Protective nasal sleeves. Endoscopic surgery through the nasal cavity can damage the mucosal lining of the nose. In collaboration with surgeons at the University of Washington in Seattle and a company based in California, we have developed a protective sheath that protects the nasal passage during surgery. The latest version will undergo clinical trials soon. Based on our initial experience, it improves visualization, minimizes damage to nasal tissues, and decreases the risk of tumor implantation during surgery. Figure shows computer modeling of surgical pathway for nasal sleeve.

Sound Sentinel drill monitoring system. Surgical drilling of bone risks injury to structures deep to the bone. Surgeons are trained to listen to a change in pitch when the bone gets thin so that they can avoid drilling too deep. Working with engineers at the Swanson School of Engineering, we have developed a device that can measure the change in pitch more accurately by analyzing the acoustic pattern and alert surgeons to avoid injury. A patent is pending and we are now working with industry to develop it further. Figure shows acoustic pattern of drilling with dural exposure.

Surgical simulation. In addition to surgical innovation, Pittsburgh CREATES provides a venue for training in minimally invasive surgical techniques. Plans are being finalized for a state-of-the-art surgical simulation center that will allow surgeons to train using a variety of modalities: 3D anatomy slide presentations, plastination of anatomical specimens, 3D printing of bone models, surgical skills training models, anatomical dissections, and computer simulation. The goal of the surgical simulation center is to train surgeons maximally before they ever step into the operating room to operate on real patients. The training facility will also be used to “retool” experienced surgeons who need to learn the latest surgical techniques.

Dr. Carl Snyderman, at right, demonstrates some of the surgical simulation materials that will be used in the new Surgical Simulation Lab. Online access to links in this issue at ISSUU: https://issuu.com/search?q=UPMC+center+for+skull+base+surgery

Decision Aid for Tumor Treatment Whether or not 35,000 is an accurate number in answer to “How many decisions does an adult make in one day?” we probably agree that we make more decisions daily than we are aware – what to eat, what to wear, what route to take, what time to be at the station, how to spend the weekend, whether to RSVP to that invitation. Our brains function like algorithms scanning “yes / no / maybe / later / this, not that” options for work decisions, leisure decisions, routine daily life decisions.

What happens when you come face-to-face with a life-altering decision that isn’t in your usual repertoire?

During a medical appointment, your physician diagnoses you with a tumor. It’s a benign tumor, noncancerous, in your auditory canal. You are presented a diagnosis of vestibular schwannoma (or acoustic neuroma). Access this link for acoustic neuroma / vestibular schwannoma symptoms.

Your physician presents you with treatment options along with expected outcomes correlated to each option.

While still processing this new situation, you begin to calculate all the “what if’s” that accompany your situation and your decision.

UPMC physicians understand that the decision process can be overwhelming for patients in the presence of emotional stress and in the number of factors that must be considered. There may be too many factors to consider; or there may be too little information, insufficient to form the best decision. Fully embracing quality of life issues as an aspect of disease on par with treatment outcome, a UPMC group is collaborating to design a tool to assist healthcare team members, patients, and family members to act as partners in the decisionmaking process.

The team, comprising Otolaryngologists and Public Health professionals from UPMC, an Epidemiologist from University of Pittsburgh and Magee-Womens Research Institute, and a Public Policy professional from Carnegie Mellon, published their initial results in the article, “Development of an evidence-based decision pathway for vestibular schwannoma treatment options,” in the American Journal of Otolaryngology.

The authors note that, given the same information, patients make different choices based on relative value attached to factors such as treatment success, side effects of therapy, risks, economic cost, quality of life, etc.

Dr. Carl Snyderman and his colleagues in UPMC Otolaryngology selected vestibular schwannoma for initial study since there is currently no clear consensus in the medical community on an optimal treatment for these tumors and the course of treatment often depends on the age of the patient, size of the tumor, comorbidities, and degree of symptoms affecting quality of life. The development of a novel decision support tool fills an important gap for patients and physicians, one that can be applied to many complex medical decisions throughout healthcare.

“We are so pleased to be involved with developing such an important tool,” says Benita Valappil, Clinical Research Director of the Center for Skull Base Surgery. “The patients who participated in the focus groups provided us the foundation to move on to the next phase of study with this tool; the progress we are making enables us to put this into use with UPMC patients very soon.”

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Patient Story: Vestibular Schwannoma Maryjane had never heard of acoustic neuroma prior to her diagnosis. The words “brain tumor” were the only words that she focused on when she got the diagnosis while at her desk at her job in accounts payable. “It makes your knees buckle,” says Maryjane, “I could not really process it, I was dumbfounded.” Then my immediate thought was, ‘What’s next?’ My doctors at UPMC explained that I didn’t need to make a decision on the spot.”

What brought Maryjane Schwickrath to this juncture? She was getting migraines and was light-headed after giving birth to her first child. Her resulting MRI indicated some non-specific white matter changes in her brain, though nothing that suggested a need for immediate action. Three years later, after giving birth to her second child, again she experienced a series of migraines and light-headedness. This time, MRI confirmed a left-sided acoustic neuroma that had not changed in size from her first MRI 3 years earlier; she was recommended a follow up evaluation in 18 months.

Maryjane resumed work and the daily routine with her husband and children, the next 6 years uneventful related to her health. Then, in one instant, she “felt funny.” “I thought I was having a stroke, I had tingling in my eye and face, my hearing suddenly changed, loud noises were much louder, everything was amplified.” She had another MRI, this one showing her tumor had grown. Dr. Barry Hirsch and Dr. Paul Gardner recommended she get it removed. When they recommended surgery, for Maryjane it was a matter of “the sooner the better.” I was thinking “yes, absolutely” before I even had a chance to think it through. As I look back on it, I recall my biggest concern was that it could be removed safely with no impact on other health areas. I did not want to be a burden to my young family.” She had left her job a few years after her initial diagnosis. After receiving the word that the tumor had grown, Maryjane says her husband encouraged her to take care of herself, do “whatever it takes!” to be well. “I was concerned, since my husband is selfemployed and jobs can be abundant or not so abundant. But we were certain we wanted to move forward with the surgery.”

In January 2013, Maryjane underwent surgery at UPMC. Drs. Gardner and Hirsch removed the tumor via craniectomy (open surgery) and Maryjane is pleased with the results. She tried to resume her lifestyle as soon as possible following surgery.

She was driving her car 2 weeks after surgery, wanting to provide her children the chance to go sledding after a snowfall. “My balance was still off at that point, so driving was a little anxiety producing, but I got through it, proceeding very cautiously.” Today, 3 years after surgery, her balance is significantly improved, though she says that “pitch black tends to throw me off balance – dark rooms, movie theaters – I hold on to walls while moving.”

When she received a letter inviting her to join a focus group on a decision-aid tool, she said yes right away. “I wanted to help. The focus group had members of varying ages and lifestyles. I sensed others in my group had more symptoms than I had and, as a result, I sensed they had more fear. Taking the survey as part of the focus group was helpful to me in that it was reassuring that I made the right decision. If you are in the process of making the decision about surgery, the survey gives clarity to what the tumor is, what the procedure is, how they do it, what it involves for you, as the patient, in terms of support you might need, costs, surgical outcomes, and other aspects related to your daily life.”

Maryjane Schwickrath

Maryjane feels confident enough in her health to schedule her follow up MRI early in the morning, then leave the office before seeing the results, with the message to “call me if I need to know something.” “My children are 9 and 12 years old; I want to be there for them, letting them do everything kids should be doing, not influenced by their Mom’s medical appointments and health. I’m teaching the kids to speak to me directly and clearly to compensate for just a minor bit of hearing loss. I’m so fortunate; I met my husband later in life; as soon as I met him, I knew I wanted a family with him. I’m glad I got the surgery, glad the tumor is gone, glad I don’t have to wait and watch for it to grow.”

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V ESTIBULAR S CHWANNOMA ?

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Former Skull Base Fellow Featured in Australia News The Adelaide Advertiser, an Australian newspaper, has highlighted Dr. Harshita Pant. Dr. Pant, the first Australian ENT surgeon to complete a Fellowship at Pittsburgh’s world-leading Skull Base Center, as a leader in the use of Endoscopic Endonasal Surgery (EES) for the treatment of skull base pathologies.

Dr. Jessica Staker

Dr. Harshita Pant

Dr. Marguerite Harding

A consultant at the Queen Elizabeth Hospital and an academic at the University of Adelaide, Dr. Pant performed a 17-hour endoscopic anterior cranial base resection to remove an invasive, aggressive neuroendocrine tumour.

Working alongside neurosurgeon Dr. Marguerite Harding and anaesthetist Dr. Jessica Staker, Dr. Pant and her team were able to entirely remove the tumour and repair the deficit without the need for an open procedure.

“The patient presented with a rare type of tumour, a neuroendocrine cancer that is known for its aggressive behaviour. Surgical options included a traditional craniotomy (open procedure) or the less invasive EES, which reduces morbidity, speeds up recovery, and offers improved quality of life and equivalent oncological results as that achieved through an open procedure.” A vital and novel element of this procedure was using an extracranial pericranial flap, rotated into the nasal cavity, to repair the skull base defect which allowed us to achieve good hemostasis (control of bleeding) while considerably reducing the risk of cerebrospinal fluid leak. Says Dr. Pant, “Such vascularised flaps were pioneered in Pittsburgh and they have allowed surgeons to not only to drastically reduce the incidence of postoperative CSF leaks, but also to push the boundaries of endonasal endoscopic surgery further.”

Dr. Pant, who has a PhD in Rhinology and Immunology, spent one year at the Skull Base Center at UPMC as a Fellow and clinical instructor in minimally invasive skull base surgery, rhinology and allergy.

She says that the Center is at the forefront of developing both open and endoscopic skull base surgical techniques. During her time at UPMC, the Skull Base Center treated more than 400 patients with a wide variety of skull base pathologies which she described as a hugely enriching experience.

“This Fellowship was uniquely established to train young ENT surgeons from two main subspecialty backgrounds – Rhinology and Head and Neck Surgery – as well as neurosurgeons,” Dr Pant said.

“Some of the major challenges presented by endoscopic skull base surgery include control of bleeding, the carotid artery, and reconstruction of skull base defects. The Pittsburgh Center has a dedicated laboratory set up to allow surgeons to master the anatomical relationships of the carotid artery, how these relationships apply to EES, the surgical skills required to work in this area and the protocols used to assess at-risk patients and manage complications.”

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Winning Pittsburgh Research Fellows Visiting research fellows from the Skull Base Center’s surgical neuroanatomy laboratory drew accolades at the 2017 North American Skull Base Society meeting in New Orleans, Louisiana.

Dr. Hamid Borghei-Razavi, visiting Fellow from Germany, won the award for Poster of Distinction for his work on “Endoscopic Endonasal Maximal Petrosectomy: Anatomical Investigation and Surgical Relevance.”

Dr. Georgios Zenonos, UPMC Clinical Fellow, presented “Bilateral Endoscopic Posterior Clinoidectomies with Separation of Kissing Carotids—A Technical Report.”

Dr. Huy Truong, visiting Fellow from Vietnam, presented “Endoscopic Transmaxillary Trans-Alisphenoid Approach to the Meckel’s Cave – An Anatomical Study.”

Dr. David Fernandes Cabral, visiting Fellow from Venezuela, presented “Endoscopic Endonasal Approach to Intrinsic Lesions: Anatomical, Radiological, and Clinical Study.”

Georgios Zenonos MD

Huy Truong MD

Hamid Borghei-Razavi MD

David Fernandes Cabral MD

Center Leaders are International Webinar Faculty The Center for Skull Base Surgery Team was invited by the Congress of Neurological Surgeons (CNS) to serve as Faculty for a 7-part webinar series on Endoscopic Endonasal Skull Base Surgery. Dr. Paul Gardner moderates sessions with a group of experts that includes Dr. Carl Snyderman, Dr. Eric Wang, and Dr. Juan Fernadnez-Miranda. Neurosurgeons around the world receive advanced academic credits for attending this webinar on the subjects of: •

Introduction to Endoscopic Endonasal Surgery

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Pituitary Tumors and Cerebrospinal Fluid Leaks

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Suprasellar/Transplanum Approaches

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Transclival/Transodontoid Approaches

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Endoscopic Endonasal Transcribriform Approaches

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Coronal Plane and Vascular Surgery

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Endonasal Skull Base Reconstruction

Online Video Bonus: Dr. Carl Snyderman and Dr. Paul Gardner are main subjects of video for a course taught in Russia.

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Center for Skull Base Surgery University of Pittsburgh 203 Lothrop Street Suite 500 Pittsburgh, PA 15213 Directors: Paul A. Gardner, MD gardpa@upmc.edu Carl H.Snyderman, MD snydermanch@upmc.edu

In future newsletters, you will learn more about new clinical, research, and educational projects initiated at the Center for Skull Base Surgery.

Your support is essential.

If you would like to learn more about our activities or sponsor a project, please contact the Eye & Ear Foundation.* To support the Center for Skull Base Surgery, please use the enclosed envelope or visit eyeandear.org. If sending a check, please make payable to the Eye & Ear Foundation.

The University of Pittsburgh Skull Base Team is pictured above.

Additional information about the educational and clinical work of the Surgeons of the Center for Skull Base Surgery is found at: UPMC.com/skullbasesurgery

www.eyeandear.org 203 Lothrop Street Suite 251 EEI Pittsburgh, Pennsylvania 15213 Tel: 412 864 1300 *The Eye & Ear Foundation is a non-profit (C)(3) organization created solely to support the educational and research efforts of the Departments of Otolaryngology and Ophthalmology at the University of Pittsburgh.

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