A premature baby with a massive tumor protruding through her cleft palate, a toddler with a mass that filled most of his skull and a child with recurrent, life-threatening nosebleeds are some of the young patients who were successfully treated by brain surgery performed through their noses.

		Graphic: Brain surgery through the nose

Experts at the University of Pittsburgh Medical Center and Children's Hospital are pioneering what they call the "expanded endonasal approach" to repair lesions in parts of the brain and spinal cord that might otherwise require dismantling of the facial bones, or in some cases are considered inoperable.

The technique uses sophisticated endoscopes, drills and other specially designed instruments that are inserted through the nose and along the anatomic equivalent of freeways to extend the surgeon's reach into the skull, explained Dr. Amin Kassam, interim chairman of the medical school's neurological surgery department.

He and his colleagues can get to problems in the frontal sinus, which is behind the forehead, down to the upper cervical spine, and over from ear to ear without harming healthy brain tissue.

In this month's Journal of Neurosurgery: Pediatrics, they describe their experience in the first 25 youngsters to be treated with the technique.

Another 25 children have since been treated in the same manner, and "we've actually not had a major complication in a child, ever," Dr. Kassam said.

He started developing the expanded endonasal approach about 10 years ago with UPMC's Drs. Carl Snyderman and Ricardo Carrau. Typically, the facial bones had to be taken apart to get to tumors and other lesions that arose behind them at the base of the skull.

Surgeons had for many years gone through the nose to operate on the pituitary gland, but did not have the equipment to go much beyond it. Dr. Kassam began adapting conventional endoscopes to get a better look up the patient's nose.

"Now the problem was you can see, but you don't know where you are going," he said. A GPS unit for other kinds of cranial surgery was brought into the mix, but it, too, needed tweaking before it mapped correctly the otherwise uncharted territory.

A special drill with an extended reach came next, followed by long instruments, named after Dr. Kassam's sons, to reach around corners. An ultrasonic aspirator, which uses high-frequency ultrasound to break up tissue and then suctions out the remains, was a "big breakthrough," the surgeon said.

The team first tried the techniques in adult patients.

"Over the last nine years, we've done 700 patients and have the largest experience in the world now with the extended endonasal approach," Dr. Kassam said. But, "when we started doing this work in adults, everybody thought we were insane."

Eyebrows were raised also when the team began using the approach in pediatric patients, but "the return for children is even greater than for adults," the surgeon said.

That's because children's facial bones are still growing, and manipulating them during conventional skull base surgery could cause disruptions that lead to disfigurement. Blood loss is also a big concern, Dr. Kassam said.

According to Desiree Eleyssami, of Orlando, Fla., the endonasal approach is just what moms would order, if they could.

Her son, 13-year-old Christian, had an extensive cyst from the middle of his forehead to the tip of his nose. It was not visible or malignant, but doctors were concerned that it would continue to grow and cause problems by pushing on nearby structures. At age 4, he had two simple surgeries, through his nose, to repair it.

When Christian was in first grade, his father noticed seeping from the scar between his nostrils. The cyst had either grown back or not been completely removed, and the boy had more surgery.

That time, though, he had a craniotomy, in which his skull was cut open from ear to ear, so doctors could get to the cyst. The scar is hidden in his hair. The boy did well until April, when his nose began to look bulbous and even turn blue. Several neurosurgeons recommended another craniotomy.

But Christian's otolaryngologist suggested that the family contact his former classmate Dr. Snyderman, who had recently delivered a professional seminar about the expanded endonasal approach.

Although a bit uncertain about the still-new procedure, the prospect of a second craniotomy had everyone in the family distraught, Mrs. Eleyssami said.

So at UPMC Presbyterian, a week before Christmas, Christian had his cyst removed through the endonasal approach. It took less than four hours, he spent one night in the hospital, and the family flew home two days after the operation. Because it was done during his holidays, the boy hasn't missed any school.

Recovery after the craniotomy was far different, Mrs. Eleyssami said.

"You're talking missing three months of school, you're in intensive care for a week. It's just a horrible thing," she said, through tears.

With the endonasal approach, she added, "the worst thing that was happening was he was having some drainage from his nose. He was in no pain. He never even took pain medicine!"

Dr. Kassam can recount many other success stories, from removing tumors to repairing aneurysms to correcting abnormal connections between blood vessels.

Problems like these are rare, so extensive experience with seeing cranial anatomy through the nose is essential to determining when the approach is an appropriate choice, he said.

Still, in some cases, as Dr. Kassam wryly noted, when Mom warned that nothing good would come of sticking things up the nose, "She was wrong."