Smilow Cancer Hospital’s new Skull Base Surgery Program is designed to make these complicated treatments more smooth and effective. “These patients need a lot of care from a lot of different teams,” said R. Peter Manes, MD, FACS, Associate Professor of Surgery, whose specialty is nasal and sinus tumors. “They need lots of different appointments and lots of different imaging studies. The idea is to give patients consolidated care. They can call one number and we’ll coordinate everything and help them navigate through the system.” “If patients can arrange to see the neurosurgeon, the ENT (Ear, Nose, and Throat) surgeon, the ophthalmologist, and the endocrinologist in a single visit, that is the ideal way to deliver our expertise,” said Sacit Bulent Omay, MD, Assistant Professor of Neurosurgery, who teams up with Dr. Manes on skull base surgeries. “And post-operatively as well, because all these specialties follow up with these patients. If it’s not well organized, they will have a new appointment every week, which is very inconvenient
“Skull base” is a broad category that includes various tumors located behind the eyes and nose, and above the base of the skull in the back of the head. The tumors can arise from the sinuses, the dura (the membrane that surrounds the brain and spinal cord), or inside the brain itself. Most skull base tumors are benign, though carcinomas and sarcomas also occur. Even benign tumors, however, can become problematic by impinging on the brain, vital nerves, and blood vessels. The tumors are tricky to reach through surgery because of their location near the brain, spinal cord, nerve centers, and major blood vessels. Removing them requires the skills of an ENT surgeon and a neurosurgeon working together.
Smilow’s program divides skull base surgeries into two categories defined by location: anterior and lateral. Drs. Manes and Omay do anterior surgeries endoscopically, another team handles lateral surgeries. The program includes about 15 physicians, including specialists from ophthalmology, endocrinology, medical oncology, and radiation oncology. Surgical techniques for treating skull neck tumors have changed drastically in the past decade. “Traditionally, surgery involved a cut along the side of the nose down to the lip,” explained Dr. Manes, “and the surgeon would basically lift the face off. For an open craniotomy, they would make a large incision on the top of the head, and then peel back the brain.” Now, for many patients, surgeons can run an endoscope through a nostril to the site of the tumor and resect it, with no disfiguring incisions or risky retraction of the brain.
These minimally invasive surgeries also reduce postoperative complications and hospital stays. Smilow is among several top cancer hospitals that have established special programs for skull base surgeries. “The tumors are really complicated and not easy to reach,” said Dr. Omay, “so they are best treated in large academic hospitals where surgical, medical, technological, and nursing support all are available.” For example, consider the process for a patient with a pituitary adenoma, one of the most common skull base tumors. The pituitary gland sits under the brain and behind the nose in a small space that’s hard to access. It also sits near the carotid artery, which feeds the brain, and the optic nerve. A pituitary tumor may push on these, causing headaches, vision problems, or other neurological issues. The patient usually seeks help first from a primary care physician, who refers the patient along to specialists. That’s how Rennie Negron ended up in surgery with Drs. Manes and Omay. Ms. Negron, who works as a research program manager at the Yale Institute for Network Science, woke up in the middle of the night with a terrible headache. She also had palsy in one eye. “I thought it was a sinus infection,” she said. She went to an urgent care center, which sent her by ambulance to the emergency room at Yale New Haven Hospital. A CT scan revealed a pituitary adenoma. Dr. Omay explains what happens next in such cases: “The first evaluation is usually an MRI of the brain to understand the nature of the tumor—where it is, the size of it, and its relationship to the neighboring structures. During the second phase, an endocrinologist evaluates the patient because pituitary tumors often disrupt hormones. Then an ophthalmologist evaluates the patient, to assess if there’s a vision issue. Next the patient is seen by an ENT surgeon, who evaluates whether the nose is feasible for the operation and if there is enough tissue to make a reconstruction afterwards. When all these consultations and evaluations are done, the patient is finally ready for surgery.”
“The tumors are really complicated and not easy to reach so they are best treated in large academic hospitals where surgical, medical, technological, and nursing support are all available.”
Smilow is among several top cancer hospitals that have established special programs for skull base surgeries. “The tumors are really complicated and not easy to reach,” said Dr. Omay, “so they are best treated in large academic hospitals where surgical, medical, technological, and nursing support all are available.” For example, consider the process for a patient with a pituitary adenoma, one of the most common skull base tumors. The pituitary gland sits under the brain and behind the nose in a small space that’s hard to access. It also sits near the carotid artery, which feeds the brain, and the optic nerve. A pituitary tumor may push on these, causing headaches, vision problems, or other neurological issues. The patient usually seeks help first from a primary care physician, who refers the patient along to specialists.
That’s how Rennie Negron ended up in surgery with Drs. Manes and Omay. Ms. Negron, who works as a research program manager at the Yale Institute for Network Science, woke up in the middle of the night with a terrible headache. She also had palsy in one eye. “I thought it was a sinus infection,” she said. She went to an urgent care center, which sent her by ambulance to the emergency room at Yale New Haven Hospital. A CT scan revealed a pituitary adenoma. Dr. Omay explains what happens next in such cases: “The first evaluation is usually an MRI of the brain to understand the nature of the tumor—where it is, the size of it, and its relationship to the neighboring structures. During the second phase, an endocrinologist evaluates the patient because pituitary tumors often disrupt hormones. Then an ophthalmologist evaluates the patient, to assess if there’s a vision issue. Next the patient is seen by an ENT surgeon, who evaluates whether the nose is feasible for the operation and if there is enough tissue to make a reconstruction afterwards. When all these consultations and evaluations are done, the patient is finally ready for surgery."
If the tumor is especially large or difficult, the surgery takes place in a special surgical suite with an intraoperative MRI. Smilow is one of the few hospitals in the country equipped with this expensive high-tech apparatus, which allows surgeons to image the patient’s tumor throughout the operation.
The tumors are really complicated and not easy to reach so they are best treated in large academic hospitals where surgical, medical, technological, and nursing support are all available.
“If we determine that there is either additional tumor or something else that needs to be done,” said Dr. Manes, “we can do it right then without moving or waking up the patient.” During the surgery itself, Drs. Manes and Omay work together closely. First, Dr. Manes guides an endoscope through the nose to the floor of the skull. “He takes me directly to the tumor,” explained Dr. Omay. “The endoscope brings a lens and a light source to exactly where the pathology is. You can park it a couple of centimeters from the tumor, so there is a beautiful visualization of what we are doing while we are operating. I do the resection of the tumor and then Dr. Manes helps with the repair.
This operation requires a team approach throughout.” During recovery and aftercare, the patient gets follow-up evaluations by the neurosurgeon, the ENT surgeon, the endocrinologist, and the ophthalmologist. “The process involves many teams,” said Dr. Omay, “which is why it’s important to perform these operations in dedicated centers.” Ms. Negron’s surgery went perfectly. Dr. Omay removed the entire tumor, and radiotherapy was unnecessary. Negron has no visual impairment, and her pituitary is functioning fine without supplemental hormonal medication.
“Essentially I have had a full recovery,” said the 32-year old. “I have a 5-year-old daughter and a husband, so being able to get back to normal soon after surgery has been really important for me and my family. Dr. Manes and Dr. Omay were amazing. The way we were able to talk to them, and how they explained the whole process and potential outcomes and challenges, was incredibly helpful through surgery and the recovery process. I couldn’t be any happier with the care and the relationships I had with them.”