Melanie Cole (Host): Welcome to the podcast series from the specialists at Penn Medicine. I’m Melanie Cole, and we have a thought leader panel for you today with three Penn Medicine experts to discuss Transorbital skull base surgery. Joining me in this panel is Dr. Christina Jackson. She’s an assistant professor of neurosurgery at the Hospital of the University of Pennsylvania. Dr. César Briceño. He’s an associate professor of ophthalmology at the hospital of the University of Pennsylvania, and the chief of the division of Oculoplastics at the Shea Eye Institute. And Dr. Jennifer Douglas. She’s an assistant professor of Otolaryngology Head and Neck Surgery in the Division of Rhinology and Skull Base Surgery at the Hospital of the University of Pennsylvania.

Thank you all so much for being with us today, and Dr. Jackson, I’d like to start with you. Can you just explain a little bit about skull-based tumors, how common they are, and really the types that you see?

Dr Christina Jackson: Of course. Thank you, Melanie. so skull-based tumors are actually not very common, but they do happen in really bad locations for our patients. They encompass a variety of pathologies. Basically, these tumors grow along the base of the skull from the front part of the skull to the back part of the skull.

They’re typically benign tumors, but the base of the skull has a lot of critical neurovascular structures, nerves that supply vision, movements of your eye, as well as vessels that supply the brain. Therefore, oftentimes these tumors, while benign, can cause significant symptoms for our patients and surgery to reach these locations can carry significant morbidity just given how deep these tumors are seated.

Host: Well, thank you for that. So, Dr. Jackson could you tell us a little bit about the Transorbital Approach, or TOA, for skull-based surgeries?

Dr Christina Jackson: So, traditionally when we used to do these procedures for patients with skull-based tumors, they often involved very large incisions on the scalp, significant removal of the bone, and very long hospital stays.

Recently there’s been a push in the field for more minimally invasive approaches using the natural corridors of our body. So the Transorbital approach is a minimally invasive surgical technique where we use the natural corridor of the eye to reach these deep areas at different parts of the base of the skull.

So instead of making a large incision on the scalp or removing a significant portion of the bone like we used to, we actually work through a very small opening. Often hidden in the natural eyelid or eyebrow to access the tumors that are seated deep in the skull base. For patients, what this means is that there’s less trauma to the brain, typically less pain after surgery, and patients typically have a faster recovery.

Of note, though, it doesn’t mean that it replaces every traditional approach, but for the right patient, it gives us a much better and safer way of accessing these areas that we used to reach through larger operations.

Host: So interesting. Dr. Briceño, since you’re in oculoplastics, tell us the benefits, expand a little on what Dr. Jackson just said of TOA when compared to other endoscopic approaches, as appearance and function of the patients can have significant impact on the patient’s quality of life.

Dr César A. Briceño: Absolutely. Thank you so much, Melanie. And so happy to be here with Dr. Douglas and Dr. Jackson because we as, ENT, neurosurgery and ophthalmology, really all exist in the region of the skull base, just in slightly different areas of it. And we encounter slightly different pathologies, but it is not uncommon that the pathologies that we encounter cross borders, which necessitates us to work with one another in order to really ensure optimal outcomes for our patients.

So, the orbit is the bony socket in which the eyeball sits, but it shares that space with a number of really important structures, many of which are vessels and nerves and muscles and fat, and all sorts of other connective tissues that are really, really important to the function of the eye and for the eyes to be able to work well with one another and also with the brain.

And so my role in this type of collaboration oftentimes is ensuring the safety of those structures. Many times the primary pathology is deeper. It’s in the skull itself, sometimes affecting the brain itself, and I need to make way for my collaborators to be able to access those structures and do the lifesaving or vision saving treatments that they do in a way that doesn’t leave too much damage in its wake.

This can be functional damage or cosmetic damage. And so working on the face or on the head and neck often has many morbidities, which are physical, but also many of which are psychological, and that sometimes comes in the form of facial disfigurement or scarring. And in oculoplastic surgery, we specialize in working in these regions of the face in order to achieve maximal exposure with minimal scarring and with minimal sequelae.

Host: This is just a fascinating discussion. And Dr. Douglas, what kinds of tumors and lesions are we talking about? What are best treated by TOA? What does the team look for when considering a case?

Dr Jennifer Douglas: Yeah. Thank you Melanie, and it’s great to be here with Dr. Briceño and Dr. Jackson. As Dr. Jackson and Dr. Briceño were reviewing, the unique asset of the Transorbital approach, really, is in some of the challenging locations that it helps us to access in a minimally invasive way. But within those anatomic regions, there can be tremendous variability in the types of pathology that can be treated.

Some of the common lesions that affect this area include neoplasms, benign tumors such as meningiomas, that involve the spheno-orbital region, the anterior clinoid, or the sphenoid wing. There can also be other anatomic conditions such as encephaloceles which may be causing CSF leaks into the nose that we can also address for this approach.

Some other tumors may involve the orbit more directly, and they can be approached in that way. But there can also be other conditions involving the bone, such as fibrosseous dysplasia, that can be causing pretty disfiguring changes in the external cranial facial structure, which can be well addressed through this approach.

More rarely, there can be inflammatory or infectious lesions such as abscesses or other conditions that we can address in this way. But what’s really important is that as a team, we are working through different corridors all the time, so we’re really able to work together and identify which condition, and which patient, can be treated in this way in the safest manner.

Dr César A. Briceño: If I can dovetail with what Dr. Douglas just mentioned. One of the areas that’s of particular interest to me is of course the orbital apex, which is to say the very back of the bony socket of the eye. Of note, this is where the optic canal is, which is the structure through which the optic nerve travels.

And this is, of course, the nerve that supplies vision. The signals are caught by the eye, and then vision happens in the brain. And so, needless to say, any structure that compresses this nerve or that somehow jeopardizes its path posteriorly to the brain and to the occipital cortex can have a pretty profound impact on vision quality.

And so as a result, we deal with this in a very gingerly and very careful way. And this is where having the expertise of Dr. Douglas and Dr. Jackson, who are very well versed in all the other structures that surround that very crowded space, it really allows us to have the best chance of dealing with the pathology with minimal fallout.

Host: That’s a great point, Dr. Briceño and Dr. Jackson, I’d like you to speak about the multidisciplinary approach and as this is a multidisciplinary procedure itself, can you describe the planning and collaborative process?

Dr Christina Jackson: Absolutely. And I think to echo what Dr. Douglas and Briceño have touched upon, we all operate in our own areas, the sinuses, the orbit, the brain, but we all meet at this area called the skull base. And I think this is what makes, this type of surgery and this type of work, really collaborative and exciting and, just great for us to work together and learn from each other, in terms of how these patients are shepherded through this procedure, because this, approach can be used for different types of procedure. The patient actually may see. Either one of us at first glance based on what brought them in and who referred them.

However, because, as you mentioned, this requires teamwork that brings different skill sets from each other. We often talk about these patients together, through a collaborative approach. So we are, all very communicative with each other and we actually have a skull base conference where experts from neurosurgery, ENT, oculoplastics, radiology, radiation oncology, and oncology all come together each week to review these difficult cases that may be good for these minimally invasive approaches to make sure that everybody’s on the same page, reviewing the same images, to ensure that we choose the best path and the best approach for these patients. And I think that 

Dr César A. Briceño: One quick thing that is important that Dr. Jackson mentioned, and that is the collaborative nature of the work between three departments. This is something that I find to be fairly unique to Penn. When Dr. Douglas and Dr. Jackson and I started to work together and came up with the concept of this team, our departments were so incredibly supportive.

And to this day I actually enjoy protected time in order to be able to take care of these patients that is, really sponsored by the Hospital of the University of Pennsylvania in order to make this possible. And so that’s yet another way in which Penn is truly special and allows us to really bring our expertise together in a really seamless way in order to help these patients get treated as quickly as possible.

Host: I’m so glad that you brought that up Dr. Briceño, because Dr. Douglas, I’d like you to give us your version about the combined clinic. You represent the three specialties. Just as Dr. Briceño just mentioned, what are you finding are the largest benefits?

Dr Jennifer Douglas: Yeah, absolutely. You know, I think our patients are always keen on more minimally invasive approaches, and a lot of what I do within the nose and the sinuses every day is, minimally invasive with endoscopic technique. So it’s been really fun to be able to apply that to a, new corridor, with a transorbital approach and come together with the skill sets of Dr. Briceño and Dr. Jackson for the team approach. You know, I think it’s pretty unique that three incredibly sub-specialized individuals and fields, can then further sub-specialize even more with this sort of approach. And as Dr. Briceño, just mentioned, it’s been incredibly well supported by the institution as a whole. We’re all constantly in communication with each other to coordinate care for our patients and facilitate things in a highly efficient manner. And I think our patients certainly benefit from that.

Host: Dr. Briceño, what does an optimal outcome look like? Have you seen an increase in optimal outcomes compared to other approaches?

Dr César A. Briceño: So, an optimal outcome from the ophthalmology standpoint, obviously, centers around visual function. Most of the cases in which I am directly involved are cases in which the vision is somehow threatened. And the most important thing besides getting rid of the primary lesion is ensuring that that visual function is preserved as much as possible.

However, there is a really important secondary outcome here, which is the cosmesis and the control or the minimization of facial disfigurement. Oftentimes, when we do larger craniotomy approaches, in the long term, you can see some atrophy of some of the tissues on the side of the head and on the side of the face that can be fairly obvious to patients, especially after their swelling subsides.

By using this corridor that comes in with a smaller incision and does not necessitate the disturbance of other normal structures in the area, we can really minimize that eventuality of tissue atrophy and the stigmata of having had prior skull-based surgery. And so a successful outcome looks not only like the preservation of vision ideally, and the resolution of the primary pathology, but also a seamless transition back to regular life. We would like for our patients to be able to rejoin their social and professional endeavors with no visible sign that they actually had to be touched by us in the first place.

And I certainly have seen many more outcomes that turn out this way as a result of working with Dr. Douglas and Dr. Jackson and I’m very, very grateful for their collaboration.

Dr Christina Jackson: I think to piggyback on that too, is traditionally, when we used to do these larger approaches for these deep-seated tumors, oftentimes we have to retract or push on the brain to get down to this deep region. The other benefit and optimal outcome I like to think about is the fact that when we do these more minimally invasive approaches, were tackling the pathology or the tumor head on and there’s very minimal disruption of the normal brain, and so that also means patients have a faster recovery out of the hospital, and like Dr. Briceño said, faster return to work and less impact on their brain function from these larger procedures previously.

Host: Dr. Douglas, would you like to chime in on what an optimal outcome looks like from your perspective?

Dr Jennifer Douglas: Absolutely. I agree with Dr. Briceño and Dr. Jackson. You know, when we think about the nose and the sinuses and how that impacts the approach with transorbital surgery, we always think about normal return to function. And so I think as efficiently as that can be obtained, we’re always prioritizing that while making sure that the primary pathology can be managed appropriately.

From a cosmetic standpoint, it’s a critically important aspect of the recovery process and ensuring that our patients have optimal outcomes. So we’re always thinking about that as well.

And then the last point I wanted to add is that I think one of the important assets of having the team approach, as Dr. Jackson mentioned, is that we’re very well versed in all of the different approaches, should they be needed. And so sometimes we’re able to combine those together.

For particularly complex lesions that may require not just one, but, a second approach as well. and sometimes that can be coordinated in a minimally invasive fashion, with both approaches versus needing a much larger single approach, with all of those other deficits from a cosmetic standpoint and a functional standpoint as well.

Host: What a lively discussion we’re having, and I’d love to give you each a chance for a final thought. So, Dr. Jackson, starting with you, tell us about some of the advancements that have been made as far as minimally invasive technology that allow surgeons to access these hard-to-reach areas of the skull that we’ve been discussing.

Dr Christina Jackson: I think one is really the invention and the utilization of endoscopy. For a lot of the cases that we do in neurosurgery, we still use the microscope, but the endoscope actually allows you to work through a narrow corridor, but provides you a much wider field of view.

And that has really pushed the boundary and allowed us to invent these minimally invasive approaches through the natural corridors. For historically the transnasal or endonasal corridor and more recently the transorbital corridor. I think the other thing really is the point of this podcast and the collaboration that we have is to have experts who are experts in their own fields, but all are interested in improving the care of these patients that we often share because their pathology lie at a intersection of neurosurgery, ENT, and oculoplastics. And so I think the collaborative efforts, as well as collaborative mindsets, for our group, is what has led Penn Neurosurgery, ENT, and Oculoplastics to really try to advance our ability to offer minimally invasive approaches to patients.

And this includes us, going to courses ourselves, going to anatomy labs to look at the anatomy in more detail, and really refining our own skill sets to offer these safer and more minimally-invasive options to patients.

Dr Jennifer Douglas: To piggyback on what Dr. Jackson just said, I think one of the really fun and enjoyable things for me being a part of this team has been to learn so much from Dr. Briceño and Dr. Jackson. You know so much about your own field, but as she said, we work so closely in different anatomic regions and so I’ve had a tremendous education, working with them in the OR and learning from their knowledge base.

And I think that makes us all better surgeons, for our, other cases, whether that’s together in these, transorbital approaches or with other procedures that we do on our own.

Host: So true. And Dr. Briceño last word to you. What do you see on the horizon for Transorbital skull base surgery for these types of tumors, for the cosmetics, as you were describing for the function and the quality of life for these patients? What would you like to see?

Dr César A. Briceño: Thank you, Melanie. I think. One of the things that I see happening in the short term, because I’m already experiencing it, is that there is cross pollination, not only of our knowledge of pathology, anatomy, and surgery, but also sharing our various surgical technologies that we typically utilize in our own worlds, but we don’t necessarily share with other specialties.

The way that we use stereotactic navigation, the way that we use different modes of hemostasis, both in terms of cautery as well as in terms of chemical hemostasis, we use them rather differently in ophthalmology versus ENT versus neurosurgery. And by coming together and being in the same space at the same time as experts in our respective fields, we cross-pollinate in that way, as well.

Hey, that particular technique might work really well in this other element of ophthalmology or this other element of neurosurgery, et cetera. And so it’s not only benefiting the patient in the room at that moment, but it’s making us all, more knowledgeable and more versatile in ways that we can help our practices even when we are not working together.

And so I think that’s one of the benefits that I’ve already started to see. As we work further into the future, what I see in the more distant horizon is also scholarship coming from our joint work. So not only can we convince ourselves that what we’re doing is more efficient and more effective, but we can also share that with the literature and with the rest of the medical world, such that the lessons that we have gleaned from our experiences can hopefully help others, to do the same.

Host: Thank you all so much for joining us today and sharing your incredible expertise in the multidisciplinary approach for these patients. Thank you so much again, and to refer your patient to Dr. Jackson, Dr. Briceño, or Dr. Douglas at Penn Medicine, please call our 24/7 provider only line at 877-937-PENN, or you could submit your referral via our secure online referral form by visiting our website at pennmedicine.org/refer-your-patient. That concludes this episode from the Specialists at Penn Medicine. I’m Melanie Cole. Thanks so much for joining us today.