Moe earned an M.D. and completed residencies in surgery and otolaryngology at UW Medicine. During fellowships at the universities of Bern and Zurich in Switzerland, he developed skills in skull-base surgery and facial plastic surgery that, in the United States, would have been outside the realm of his specialty training.
Later, when Moe was performing transnasal pituitary tumor surgery and orbit-repair surgeries at the UC San Diego School of Medicine, the seeds of a new idea were sown.
“These concepts started coming to me,” Moe explains. “I had two interests — facial plastic surgery and skull-base surgery — transorbital surgery is where these intersect.” Upon his return to UW Medicine in 2006, Moe began pursuing the idea with colleagues.
Teamwork was key to developing TONES. “The UW offers a really great collaborative working environment,” says Chris M. Bergeron, M.D., Fel. ’08, assistant professor of surgery in the Division of Head and Neck Surgery at UC San Diego Health System. Bergeron trained with Moe at UW Medicine and helped develop TONES. “In doing pituitary surgeries together, we began to wonder, ‘What stands in the way of us getting to that spot in the brain?’”
Approaching the skull base or the front of the brain from above means performing a full craniotomy, resulting in a large, ear-to-ear scar. And when approaching that area from below via transnasal surgery, the size of the nostrils limits the number of instruments that can be used at one time, as well as the number of hands that can work at once.
In addition, says Manuel Ferreira, M.D., Ph.D., Fel. ’10, UW assistant professor in the Department of Neurological Surgery and co-director of Skull-base and Minimally Invasive Neurosurgery at Harborview, “the big downfall with transnasal approaches is the morbidity associated with cerebrospinal fluid leaking.”
“When you leak this fluid into a non-sterile environment, the risk of meningitis is high,” Ferreira says. While the natural barrier between the brain and the pituitary lowers this risk in transnasal pituitary tumor surgery, treating pathologies such as skull-base tumors and trauma-induced CSF leaks with transnasal surgery is more risky.
“Going through the eye, you’re going from a sterile space to a sterile space,” Ferreira explains. “You get the benefit of greater access, and the lobes of the brain hold pressure on your new construct, which helps prevent the spinal fluid leaking.”
After developing the technique on cadavers, Moe and Bergeron began using TONES on patients with post-traumatic injuries, and then on patients with other pathologies. “The results are phenomenal,” says Ferreira.