Individualizing Treatment of Skull Base Disorders

UH Institutes collaborate for multidisciplinary skull base program

Innovations in Neurology & Neurosurgery and Innovations in Ear, Nose & Throat

Nicholas Bambakidis, MD

Alejandro Rivas, MD

Cranial skull base disorders, including complex tumors such as acoustic neuroma, are rare — with the largest U.S. medical centers treating fewer than 180 cases per year. Because these disorders often involve not just the brain, but also the nerves that encompass hearing, facial expression, vision and balance, treatment requires a multidisciplinary approach.

“Research clearly shows that patients with acoustic neuromas and other skull base pathologies have better outcomes when treatment is performed in a multidisciplinary manner,” explains University Hospitals’ Neurological Institute Vice President and Director, Nicholas Bambakidis, MD, who also serves as President of the Congress of Neurological Surgeons (CNS).

UH Neurological Institute has a long history of close collaboration with its physician-partners in otolaryngology, Dr. Bambakidis says. The multidisciplinary skull base team at UH is comprised of neurology and otolaryngology specialists, including ENT (ear, nose and throat) surgeons, maxillofacial surgeons, neurosurgeons who specialize in lateral, endoscopic and open skull base surgery, radiologists, nurse practitioners and neurotologists.

In fact, UH is growing one of the largest neurotology programs in the country with Alejandro Rivas, MD, who was recently recruited from his role as Director of Endoscopic Ear Surgery at Vanderbilt University Medical Center to become Division Chief of Otology/Neurotology at University Hospitals Ear, Nose and Throat Institute and five additional neurotologists now available to the system: Sarah Mowry, MD; Maroun Semaan, MD; Nauman Manzoor, MD; Cliff Megerian, MD.

With its growing team of specialists, innovative skull bases approaches, exceptional operating times and outcomes, multiple options for radiation when needed, a premiere balance, hearing and physical rehabilitation team, and more, Dr. Rivas says UH has all the ingredients needed to be a leading national skull base center.

“We have a unique opportunity to provide world-class, comprehensive care in cochlear implantation, skull base surgery, and all related auditory, balance and ear pathologies,” he says. “It comes down to having a multidisciplinary approach to each specific patient. We discuss every skull base case that comes to UH each month, so we can find the right option for every individual.”

Having a coordinated team of different experts with different strengths ensures skull base patients can get the individualized care they need, comfortably and in the fewest possible visits, he explains.

“We make our best efforts to coordinate all appointments into the least amount of visits possible, hoping to minimize disruption to the patient’s lifestyle,” Dr. Rivas says. “So, as a patient, I can take one day off to go get my MRI, hearing test and balance test, and then go see the skull base neurosurgeon and neurotologist that same day. That way, after a one- or two-day visit, each patient has an in-depth understanding of what his options are. He and his team can make a meaningful decision on what the best next step in the patient’s care will be.”

Skull base center of excellence

Under the expert leadership of Dr. Rivas and Dr. Bambakidis, UH is currently developing a skull base center of excellence — one of six new centers being created. Plans include expanding the skull base laboratory at UH Neurological Institute as well as developing a premier ENT/neurosurgery simulation center in Northeast Ohio.

These efforts will put UH on the forefront of education and surgical training in skull base treatment for its residents and fellows, and the larger medical community.

Today, UH skull base specialists can already access some of the latest medical technologies, such as 3D imaging and artificial intelligence, to evaluate skull base tumors and pathologies. However, Dr. Bambakidis, who is also Professor of Neurological Surgery at Case Western Reserve University School of Medicine, says the expanded skull base lab will further build out the infrastructure and technology, such as new microscopes, camera systems and other educational equipment. “Dr. Rivas is bringing his expertise in skull base surgical procedures to expand our lab and provide that hands-on training for physicians practicing skull base procedures, locally and beyond,” he says.

That includes ENT surgeons or neurosurgeons in the community, as well as those nationally and internationally who want to learn about surgical options using the newest technologies. By renovating and reconfiguring the UH ENT/NI Surgical Simulation Lab, the skull base center will also have a dedicated space for training, recruiting and retaining top ENT and neurosurgery specialists.

“Having both specialties under one roof is crucial to create a collaborative training environment that I believe will bring the biggest breakthroughs in innovation in our respective fields,” says Dr. Rivas, who was one of the first physicians to use transcanal endoscopic ear surgery (TEES) for minimally invasive treatment of acoustic neuroma. “This will allow our neurosurgery and ENT trainees to explore together the intricacies of the head, neck, brain and base of the skull and create a symbiotic relationship with each other, which will be needed later on in their daily practice — similar to the relationship I have with Dr. Bambakidis.”

Regarding TEES, he adds, “In very few cases, we can remove an acoustic neuroma through the ear canal instead of making incisions from behind,” he explains. “Although it is not an option for every patient, it makes the surgery shorter, with a smaller incision and decreased morbidity. The simulation lab would be the perfect setup to teach this type of approach.”

Another goal for the Simulation Center is to give companies a place to showcase new and innovative medical products — giving UH surgeons a pipeline to the latest technologies.

Staying the course

The COVID-19 pandemic has slowed some of this momentum, but UH’s rapid implementation of telehealth has ensured that progress continues.

On October 16 and 17, 2020, UH held its first combined microscopic and endoscopic ear surgery course for residents in the region. Physicians took all the necessary precautions and safety measures needed during the COVID-19 pandemic. The multidisciplinary skull base team will also hold a temporal bone lab in October, which is designed with social distancing and separate lab stations. “We also have educational speakers coming through telehealth,” Dr. Rivas says. “It comes down to finding different ways to achieve the same goal.”

For the past several years, Dr. Bambakidis has also hosted two major skull base courses at UH, where neurosurgeons from around the country and world congregate to review the latest updates in skull base surgery. In 2020, these courses have been replaced by a virtual webinar series hosted by the CNS.

The growth of telehealth is ultimately improving access to care for skull base patients, as well.

“We can now treat our patients from the comfort of their home and minimize visits before surgery for acoustic neuromas or cochlear implantation, while maximizing the coverage for our Northeast Ohio and out-of-state population,” Dr. Rivas says.

To refer a patient to UH Neurological Institute or contact one of our experts, call 216-553-1778.