The multidisciplinary skull base team at UNC is now in full operation. The group is now routinely meeting to discuss a variety of skull base lesions and their management. We remain strongly committed to the concept of offering patients a balanced and unbiased opinion with all avenues being explored. The scope and experience of this group is vast, thereby providing patients the opportunity for a truly comprehensive evaluation.

In 2009, the Skull Base Center was very active in a variety of areas. In the anterior skull base, together with their neurosurgery colleagues, Drs. Senior and Zanation extended their already robust experience with endoscopic pituitary and parasellar surgery. These cases are now routinely being done with 2-3 days in the hospital and rare need for intranasal packing. Moreover, these surgeons are now routinely extending endoscopic tumor resections in the anterior base of skull to the clivus and petrous apex without the need for external incisions. This approach is significantly reducing patient morbidity without compromising tumor removal. Quite notably, Drs. Zanation and Germanwala also successfully accomplished the first, purely endoscopic, transnasal clipping of 2 anterior circulation aneurysms. Importantly, in this particular case, the endoscopic surgical exposure allowed for better visualization than conventional open approaches, again without the need for external incisions or a formal craniotomy. This novel approach further extends the surgical armamentarium of the endoscopic skull base surgeons at UNC and might redefine the way selected lesions should be managed in the future.

In the posterior and lateral skull base, together with their neurosurgery colleagues, Drs. Buchman and Adunka performed a variety of skull base tumor surgeries in 2009. Notably, hearing preservation has become commonplace among many patients undergoing acoustic tumor surgery, owing to refinements in surgical techniques and experience. We also continue to have excellent results in the broad areas of functional neural preservation and even restoration in some cases. We also continue to combine a variety of surgical exposures and reconstruction techniques in this area to manage complex lesions.

At UNC, growing number of patients are electing treatment with the Cyberknife Radiosurgery Unit for a variety of lesions related to the base of skull. Some examples of these lesions include: vestibular schwannoma (acoustic neuroma), meningioma, pituitary adenoma, trigeminal neuralgia, to name a few. Moreover, patients with malignant disease have also been treated in selected cases as well. This technology has certainly increased our ability to treat patients that otherwise might have been considered untreatable in the past.

Background and Philosophy:

Historically, the complex anatomical relationships of many important structures within the base of the skull have made treatment paradigms particularly morbid for afflicted patients. Recent advances in surgical approaches, cranial nerve monitoring, endoscopic visualization, intraoperative imaging and navigation, neuroendovascular techniques, as well as intraoperative and stereotactic radiation have allowed dramatic improvements in patient outcomes and quality of life. Many of these improvements have been directly attributable to close collaborations between a variety of medical disciplines including Neurosurgery, Otolaryngology-Head & Neck Surgery, Radiation Oncology, Neurointerventional Radiology, and rehabilitative disciplines. For example, surgical approaches developed by rhinologists and neurotologists have allowed neurosurgeons access to tumors and other lesions involving the skull base without the need for traumatic brain retraction, resection, or in some instances, skin incisions. Moreover, working together, surgeons and radiation therapists have been able to apply precise anatomic knowledge to the delivery of highly focused radiation in an effort to avoid collateral tissue damage.

Skull base lesions are uncommon and clinical trials for treating many of these lesions are lacking. Patients are frequently left to seek opinions from a variety of clinical specialists including medical and radiation oncologists as well as surgeons in an attempt to find a consensus regarding optimal therapy. However, opinions are frequently divergent and dictated by the practitioner’s area of expertise rather than by patient factors. This creates significant uncertainty among both patients as well as referring physicians during difficult times.

Nationwide, there are very few dedicated skull bases centers that provide a truly multidisciplinary approach to the management of such tumors. Most centers use either a “surgery-centric” or “radiosurgery-centric” model depending on the institution’s expertise and interest. This institutional bias might not serve the patients’ best interests. At UNC, we are fortunate to have a unique skull base program that combines professional experience and skills, cutting edge technologies and facilities, and a burning desire to provide a balanced and unbiased opinion of the treatment options that serves the patient’s best interests. Cooperation through mutual respect for one another’s skills and opinions forms the backbone for this eclectic treatment philosophy.

Both Neurosurgery and Otolaryngology-Head & Neck Surgery have recently added new faculty members with special interests and training in this area. Radiation Oncology has also recently added the Cyberknife Radiosurgical System to the radiation-based treatment armamentarium. This system has a dedicated nurse coordinator for patient care. The Cyberknife System has a number of distinct advantages over its competition in that it allows for precise frameless delivery of either single dose or fractionated dose radiation to tumors throughout the body including the skull base.

Dr. Craig Buchman serves as Director of the new UNC Skull Base Center. Others from the Department of Otolaryngology-Head and Neck Surgery who are directly involved include Drs. Oliver Adunka, Marion Couch, Harold Pillsbury, Brent Senior, William Shockley, and Adam Zanation, as well as nurses Barbara Esterly, RN, B.J. Squires, RN, Soonyoung Rondinelli, RN and Sean Gallagher, RN.

Other UNC Disciplines Involved:

Neurosurgery: Drs. Matthew Ewend and Anand Germanwala

Radiation Oncology: Dr. David Morris

Endocrinology: Dr. Julie Sharpless

Ophthalmology: Drs. Syndee Givre and Jonathan Dutton

Neuroradiology: Drs. Mauricio Castillo, Valerie Jewells, Keith Smith, Sten Solander, and Benjamin Huang

Neurology: Dr. Jerry Greenwood

Medical Oncology: Dr. Neil Hayes

Nursing: Sharon Cush, RN, and Pasha Lemnah, RN

Rehabilitation: Diane Meyer, PT