Direct Puncture Embolization of Sinonasal/Anterior Skull Base Tumors

Objective: It is becoming more common to approach sinonasal and skull base tumors using transnasal endoscopic approaches. One of the difficulties encountered with this approach is excessive bleeding from the tumor which makes the procedure challenging and may obscure the evaluation of margins. Preoperative embolization of vascular head and neck tumors has been well described to reduce operative blood loss and operative time. Traditionally, this is performed using a transarterial approach. In this series we aim to report our results with transnasal direct puncture embolization of sinonasal/anterior skull base tumors.

Design: Case series with retrospective chart review.

Setting: Tertiary care academic otolaryngology practice.

Subject and Methods: Seven patients who underwent preoperative direct puncture embolization by a single interventional neurosurgeon from 2011 to 2016 were included in this study. Patients were excluded from the study if no embolization could be performed or if patients were lost to follow up. All patients underwent direct transnasal embolization of sinonasal/anterior skull base tumors with Onyx-18 or n-butyl-2-cyanoacrylate under direct visualization and fluoroscopic guidance. Following this, they underwent transnasal endoscopic resection of the tumor. Various data points were recorded including baseline patient demographics, tumor characteristics, duration of fluoroscopy, amount of contrast used, percent devascularization, time to surgical resection, operative time, operative blood loss, number of blood transfusions, postoperative complications, and postoperative bleeding.

Results: Patients ranged from 14 to 71 years of age. Six patients were male and 1 was female. Tumors included were three juvenile angiofibromas, one hemangiopericytoma, one metastatic renal cell carcinoma, one glomangiopericytoma, and one sinonasal sarcoma. The average fluoroscopy time was 45.1 minutes (range: 15.4–140.4 minutes). The average amount of contrast (Visipaque 320) used was 119.2cc (range: 60–200 cc). The average operative time was 316 minutes (range: 162–535 minutes). The average blood loss was 508 cc (range: 150–1,000 cc). The average transfusion need was 1 unit (range: 0–3 units). Devascularization rates were available for 5 of the patients. The mean percent devascularization for JNAs was 93%. The metastatic RCC reached 80 to 90% devascularization. The glomangiopericytoma reached 50% devascularization. There were no post-operative bleeding complications. There was one case of postoperative occipital scalp alopecia.

Conclusion: Direct tumor embolization of sinonasal/anterior skull base tumors can be safely and effectively performed. Certain disadvantages of traditional transarterial embolization include subtotal embolization in cases where there are extensive, arborized vasculature, risk of inadvertent embolization in cranial nerve nutrient arteries or cerebral or retinal circulation if intracranial-to-extracranial anastomoses are present. Direct puncture embolization is a method that may reduce the risk for these complications. In our series, we obtained near total devascularization for most of the patients. This allowed us to perform transnasal endoscopic resections of these tumors with overall reasonable blood loss and need for transfusion. We did not have any operative complications; however, one patient did develop occipital alopecia felt to be secondary to radiation from the fluoroscopy. Overall, direct tumor embolization for sinonasal/anterior skull base tumors has proven to be safe and effective.