Skull-base surgery: NS vs ENT

[CutIt]

Can anyone detail how much skull-base surgery is performed by ENT doctors vs neurosurgeons?

Thanks

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[neutropeniaboy]

Originally posted by CutIt
Can anyone detail how much skull-base surgery is performed by ENT doctors vs neurosurgeons?

Thanks

ENT surgeons don't do very much of it, unless you are fellowship-trained in head and neck oncology or neurotology. Even then, I don't think it happens that often.

I can't speak for the neurosurgeons.

 

[ArrogantSurgeon]

ENTs usuallly don't go around the S-B, as it is the domain of neurosurgeons. Even the neurosurgeons who operate there usually do a fellowship after their core neurosurg residency.

 

[DuneHog]

It varies by institution, but fellowship trained otologists/neuro-otologists do resections of acoustic neuromas and other CP angle tumors, often in conjunction with neurosurgeons. I've also seen otologists do facial nerve decompressions in selected cases of temporal bone fractures. I think most otologists are pretty comforatable with a temporal bone approach to the middle cranial fossa, probably more so than a neurosurgeon who hasn't done a skull base fellowship. Also, an ENT would certainly be involved in the resection of a nasopharyngeal carcinoma that extends into the skull base (although a lot of these are unresectable). The only other skull base work I can think of that an ENT would be involved in would be to provide the approach for a trans-sphenoidal pituitary resection, with the resection itself done by neurosurgeons. Anything in the posterior cranial fossa would be clearly in the realm of the neurosurgeon.

 

[Idiopathic]

Dont you guys watch "Everwood"? If Treat Williams can do a S-B- procedure, then certainly an ordinary ENT can, also.

 

[CutIt]

Then what do ENTs who complete skull-base fellowships after residency do? Do they just assist neurosurgeons with facial approaches to the skull base?

 

[DuneHog]

Originally posted by CutIt
Then what do ENTs who complete skull-base fellowships after residency do? Do they just assist neurosurgeons with facial approaches to the skull base?

Perhaps you misunderstood. Skull base is a fellowship of neurosurgery, not otolaryngology. Fellowships for otolaryngolists in Otology/Neurotology includes training in skull base surgery. Otologists are really the masters of the temporal bone, which is of course a major componant of the skull base. Because both the 7th and 8th cranial nerve run through the temporal bone, otologists treat tumors and other problems that affect these nerves as they run their course from the brainstem through the temporal bone (like acoustic neuromas). Some otologists do work closely with neurosurgeons that specialize in skull base surgery, but otologists also treat all other aspects of ear disease and do everything from tympanoplasty to stapedectomy to cochlear implants.

 

[eddieberetta]

Skull base is a neurosurgical fellowship. The related ENT fellowship is otology which includes certain skull base surgeries. It is important to realize that skull base work can be done by neurosurgeons by themselves (common), by neurosurgeons working with otologists (common) and by otologists alone (uncommon). Otologists will provide the approach for trans-sphenoidal (pituitary) surgery, trans-labyrinthine (acoustic) surgery and anterior cranial fossa/sinus/oncology combined operations. By themselves, some otologists will resect acoustic neuromas using the trans-labyrinthine approach (this is an approach that is less commonly used by neurosurgeons) --- others will provide the approach and let the NSx resect.

However, by the same token, neurosurgeons commonly resect acoustics using other approaches (trans-temporal-MCF, sub-occipital, etc.). Some neurosurgeons feel comfortable doing trans sphenoidal and trans labrinthine approaches without help.

Although these are the main areas of intersection between ENT and NSx in terms of skull base, it is important to note that skull base NSx includes other operations (aneurysm, tumor, meningioma) in this region and otology includes operations of the middle ear (TM, cholesteatoma, ossicle), inner ear (cochlear), petrous bone (aneurysm, osteomyelitis) and mastoid.

 

[DuneHog]

Originally posted by eddieberetta
Otologists will provide the approach for trans-sphenoidal (pituitary) surgery, trans-labyrinthine (acoustic) surgery and anterior cranial fossa/sinus/oncology combined operations.

Trans sphenoidals and anterior cranial fossa surgery would more likely be performed by an otolaryngologist with training in head and neck oncology or sinus surgery, not an otologist (although an otologist may be comforatable with some of this depending on where they did their ENT residency).

 

[bobbyseal]

We have a neurosurgeon who took a fellowship in skull base surgery at my University. I like to think of him as the king of the fossa.

From what he said the surgery is very meticulous, lasting many hours. Many of the operations involve removal of meningiomas. That can be very tiresome since you have to clear out an tumor lying on top of a nerve. Very slow, very cumbersome.

He also pointed out that ENT goes hand in hand with skull base. Often they tag team on an operation where the ENT will get him access to the fossa that he needs to work in. Then he operates and finally the ENT comes back to close up.