At the Skull Base, Mapping a Complex Landscape

Lee Zimmer, MD, PhD, left, with his friend and colleague, Philip Theodosopoulos, MD. Photo by UC Academic Health Center Communications Services.

Some people are joined at the hip. The UC Gardner Neuroscience Institute’s Lee Zimmer, MD, PhD, and Philip Theodosopoulos, MD, are joined at the skull base in a five-year partnership that is giving them national stature as pioneers in brain anatomy. At the 21st annual meeting of the North American Skull Base Society, held recently in Scottsdale, Ariz., they presented an eye-popping seven abstracts, a number matched or exceeded by only a handful of other physicians among the 500 represented.

Dr. Zimmer, Associate Professor of Otolaryngology-Head and Neck Surgery at the University of Cincinnati College of Medicine, and Dr. Theodosopoulos, Associate Professor of Neurosurgery, are passionate about figuring out how to operate more effectively in the skull base, a complex, cavernous area that involves the nasal passages and the lower part of the brain. As members of the UC Brain Tumor Center team, they spend 15 to 20 hours together each week, practicing in the cadaver lab, mapping surgical strategies, and operating, with Dr. Zimmer’s surgical instruments ending where Dr. Theo’s begin.

Their recent abstracts included:

  • identifying “Muller’s muscle” as an anatomical landmark;
  • answering the quality-of-life question of whether people can still smell after a transnasal endoscopic approach to the sella (the answer is yes); and
  • exploring decompression of the optic nerve following compression by a tumor (stay tuned!)

“There is a lot to discover,” Dr. Zimmer says. “We are getting to know the landscape.”

The plethora of research from Drs. Zimmer and Theodosopoulos helps confirm their status as two of the most forward-thinking skull base surgeons in North America. Dr. Theodosopoulos has described their careers as coinciding with “the dawn of a new era” in minimally invasive cranial surgery. At the same time, they are building on a long tradition of excellence in skull base surgery, which was established in the 1990s by Myles Pensak, MD (below left), the H.B. Broidy Professor and Chair of UC’s Department of Otolaryngology, and John M. Tew, MD (below right), a Mayfield Clinic neurosurgeon and UCNI’s Clinical Director.

In a nutshell, Drs. Zimmer and Theodosopolous are exploring new pathways, or approaches, to tumors through the skull base by following natural anatomical corridors and landmarks and causing minimal disruption of tissue. They are solving problems endoscopically – with incisionless surgery – that previously were performed through an opening in the skull.

“I wouldn’t say these pathways are safer – that’s yet to be determined,” Dr. Zimmer says. “But they are new pathways, endoscopically, through the nostrils. They definitely help patients have faster recoveries.”

Dr. Zimmer begins a procedure by entering the skull base via the nostrils with an endoscope, a long narrow tube with a light and camera at the end. He and Dr. Theo then use additional tools to remove brain tumors of the skull base, including pituitary tumors and meningiomas. They are also capable of repairing cerebrospinal fluid leaks and eradicating cholesterol granulomas, benign cysts that can occur in a portion of the skull near the middle ear.

Together, Drs. Theodosopoulos and Zimmer have built a significant sub-specialty practice in pituitary tumor removal. In 2010 they treated about 90 patients with pituitary tumors.

The two surgeons also help train future skull base surgeons. In March they were course directors for their third annual two-day seminar, “Advanced Endoscopic Cranial Base Surgery Course,” in Cincinnati, and last week they trained 40 medical residents at the American Association of Neurological Surgeons (AANS) annual meeting in Denver.

One secret to their success is their genuine friendship. “You have to get along with each other, that’s No. 1,” Dr. Zimmer says. “We do humor and critique each other. We’re not afraid to pick each other’s minds.”

Barely into their 40s, they enjoy get-togethers with wives and children. Their biggest difference is political. “I think I’m more analytical,” Dr. Zimmer says, “and he’s more philosophical.”

— Cindy Starr

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