Combining Forces for a One-of-a-Kind Skull Based Surgery Team at LVHN

The base of the skull is a crowded and complicated place. The bones that form the bottom, or base, of the cranium also form the eye socket, roof of the nasal cavity and sinuses, and the temporal bone (the bone that surrounds the inner ear hearing and balance mechanism). It is full of openings that the spinal cord, blood vessels (e.g., carotid artery) and nerves pass through. When medical attention is required in the skull base, it calls for a team of surgeons, with each member specializing in one of these delicate and hard-to-reach areas.

Lehigh Valley Institute for Surgical Excellence, part of Lehigh Valley Health Network (LVHN), has all the elements of an outstanding skull base surgery program here in eastern Pennsylvania. “We have the surgical skills, and we have the technology, now we just need to get the word out,” says Walter Jean, MD, Chief, Division of Neurological Surgery, with Lehigh Valley Fleming Neuroscience Institute, also part of LVHN.  

Dr. Jean, a pioneering neurosurgeon who speaks all over the world, came to the Lehigh Valley from George Washington University Hospital in Washington, D.C., specifically for the skull base surgery program at LVHN. He helped build the rest of the team, consisting of Ravi Samy, MD, Chief, Division of Otolaryngology-Head and Neck Surgery; Randolph Wojcik, MD, Chief, Division of Plastic Surgery; otolaryngologists Sean Parsel, DO; radiation oncologist Robert Prosnitz, MD; and otolaryngologist Chetan S. Nayak, MD. Together, the team has 75-plus years of experience.

“LVHN is moving into more complex things, but there is no little thing with complex surgery,” Dr. Samy says, emphasizing the importance of truly understanding multidisciplinary care. Beyond the surgery, you need the highest-level consultants, intensive care units, neuroradiology and other aspects of comprehensive, world-class care.

“Patients can do great in the hospital, go home and something happens,” he says. “We need to maintain comprehensive oversight, with all the parts working together like a symphony. And the preoperative phase is almost as important as the intraoperative and postoperative phases.” 

The multidisciplinary procedures in skull base surgery may remove either noncancerous and cancerous growths, as well as abnormalities on the underside of the brain, at the skull base or on the top few vertebrae of the spinal column. Because this is such a difficult area to see and reach, there are different approaches to treatment.

“Ninety percent of procedures involve tumors, and the majority are not cancerous,” Dr. Jean says. “The most common are acoustic neuromas, those affecting the nerves supplying the inner ear, and anterior pituitary tumors, located in the front portion of the pituitary gland.”

According to the team, there are four primary approaches to treatment, all depending on the individual patient and condition.

• Endoscopic surgery is conducted through the sinus cavity or the nostrils.
• A craniotomy is traditional, open surgery where portions of the skull are temporarily removed to gain access to the tumor.  This craniotomy can also be performed through, around, or above the ear.
• Radiosurgery, often using the Gamma Knife, involves beams of radiation to destroy the tumor.
• Watchful waiting means monitoring the growth of the tumor without surgery.

While most tumors the team encounters are benign, they are still serious concerns for the surgeons.

“Even though benign tumors don’t kill you, they can wreck your life if they are not taken care of properly,” Dr. Jean says. “They can affect hearing, balance, smell, taste, eyesight – all your senses. That’s why having skilled surgeons is so important. Patients can suffer for many years without proper care.”

Helping the team navigate this anatomical jungle and these various techniques is surgical navigation technology that combines patient imaging studies with intraoperative real-time data to improve surgical precision and patient outcomes.

Preoperative planning with computed tomography (CT) scans and augmented reality (AR) systems act like GPS – equipped with a heads-up display – guiding the surgeons to the tumor. AR platforms overlay or mix simulated digital imagery with real life, offering better visualization of the area for mapping out a surgery before it’s conducted. Technology-aided microscopes project images onto the patient, guiding the surgeons at each step. This results in movements that are more precise, reducing surgery time, recovery and even the size of the incisions.

And while technology provides incredible advantages to both the surgeons and the patients, the team agrees it is never a substitute for experience and a kind word. 

“We use robotics, CT scans, AR – all the state-of-the-art stuff,” Dr. Samy says. “But I find it means much more to patients that all this is built on a bedrock of kindness and compassion. Technology is cool, but patients really just want to know that you’ll be there for them.”