A detailed look at the surgery by Dr. Juan Maza-Solano
At surgical training app SurgSchool, we continually strive to bring you the most educational and enriching surgical content. Today, we are excited to share an enlightening video on the surgical approach to nasal Schwannoma, masterfully performed by Dr. Juan Maza, a renowned rhinologist at the Virgen Macarena University Hospital in Seville.
Understanding Nasal Schwannomas
Nasal Schwannomas, part of the category of head and neck Schwannomas, make up 30 to 45% of extracranial Schwannomas. Of these, approximately 4% are located in the nasoethmoidal complex. This rare tumor presents unique challenges due to its proximity to critical olfactory structures.
Surgical Approach
The surgery begins similarly to a draft procedure used to locate the olfactory fibers. The initial steps involve making an incision and blunt dissection of the periosteum of the nasal cavity using cottonoids to identify the first olfactory fibers.
As the dissection progresses, the edges of the tumor gradually expand to expose the entire cribriform area associated with the olfactory fibers. Precision is crucial at this stage to avoid damaging delicate structures and ensure complete exposure of the tumor site.
Critical Dissection and Tumor Resection
Once the olfactory fibers are located, a meticulous dissection is performed near their origin under endoscopic guidance to prevent cerebrospinal fluid (CSF) leak. A small safety margin is maintained, which is carefully reviewed to ensure complete resection of the tumor.
In particularly sensitive areas, bipolar forceps are used to achieve safer resection without causing CSF leak. The precision of this tool helps to effectively handle the delicate tissue around the olfactory fibers.
Ensuring Hemostasis and Addressing CSF Leak
After tumor resection, the surgical site undergoes thorough hemostasis. The endoscopic view helps to identify even the slightest CSF leak from the cribriform area adjacent to the surgical bed. Careful resection of the Schwannoma-dependent olfactory fibers is performed to avoid exacerbating the CSF leak.
In the final stages, bipolar forceps are used again to promote meningeal retraction, helping to reduce CSF leak. The anterior olfactory fibers are meticulously resected and the surgical bed is checked with bipolar forceps to ensure that there is no further CSF leak.
Final Steps: Sealing and Stabilization
Despite not observing post-bipolarization CSF leak, the initial presence of leak required the use of a free nasal floor flap to reinforce the seal. The flap was stabilized with Tachosil and Surgicel strips, followed by resorbable nasal packing to ensure optimal healing.
