Endoscopic Endonasal versus Open Repair of Anterior Skull Base CSF Leak, Meningocele, and Encephalocele: A Systematic Review of Outcomes

Abstract OBJECTIVE The anterior skull base, in front of the sphenoid sinus, can be approached using a variety of techniques including extended subfrontal, transfacial, and craniofacial approaches. These methods include risks of brain retraction, contusion, cerebrospinal fluid leak, meningitis, and cosmetic deformity. An alternate and more direct approach is the endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach. METHODS An endoscopic, endonasal approach was used to treat a variety of conditions of the anterior skull base arising in front of the sphenoid sinus and between the orbits in a series of 44 patients. A prospective database was used to detail the corridor of approach, closure technique, use of intraoperative lumbar drainage, operative time, and postoperative complications. Extent of resection was determined by a radiologist using volumetric analysis. RESULTS Pathology included meningo/encephaloceles (19), benign tumors (14), malignant tumors (9), and infectious lesions (2). Lumbar drains were placed intraoperatively in 20 patients. The CSF leak rate was 6.8% for the whole series and 9% for intradural cases. Leaks were effectively managed with lumbar drainage. Early reoperation for cerebrospinal fluid (CSF) leak occurred in 1 patient (2.2%). There were no intracranial infections. Greater than 98% resection was achieved in 12 of 14 benign and 5 of 9 malignant tumors. CONCLUSION The endoscopic, endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach is versatile and suitable for managing a variety of pathological entities. This minimal access surgery is a feasible alternative to transcranial, transfacial, or combined craniofacial approaches to the anterior skull base and anterior cranial fossa in front of the sphenoid sinus. The risk of CSF leak and infection are reasonably low and decrease with experience. Longer follow-up and larger series of patients will be required to validate the long-term efficacy of this minimally invasive approach.

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Is a Single-Dose, Single-Agent Perioperative Antibiotic Protocol Adequate for Endoscopic Endonasal Skull Base Surgery? A 10-Year Review of 422 Cases

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713771 ◽

2020 ◽

Author(s):

Mark A. Hughes ◽

Nick Phillips ◽

Atul Tyagi ◽

Asim Sheikh ◽

Kavita Sethi ◽

...

Keyword(s):

Single Dose ◽

Skull Base ◽

Skull Base Surgery ◽

Single Agent ◽

Prophylactic Antibiotic ◽

Antibiotic Use ◽

Anterior Skull Base ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Postoperative Meningitis

Abstract Objectives Postoperative meningitis is a rare but potentially fatal complication of endoscopic endonasal skull base surgery. Prophylactic antibiotic use varies considerably worldwide. We sought to analyze the safety of a single-agent, single-dose protocol. Design, Setting, and Participants A retrospective review of 422 procedures performed during 404 admission episodes from 2009 to 2019, encompassing sella, parasella, and other anterior skull base pathologies. Main Outcome Measures Primary outcome measure was development of meningitis within 30 days of surgery. Additional information collected: underlying pathological diagnosis, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, and primary or revision surgery. Results Of 404 admission episodes for endoscopic anterior skull base surgery, 12 cases developed meningitis. Seven had positive CSF cultures and all 12 recovered. For pathology centered on the sella (including pituitary adenoma), the rate of meningitis was 1.1% (3/283). For pathologies demanding an extended approach (including meningioma and craniopharyngioma), the rate of meningitis was 14.5% (9/62). Postoperative CSF leak requiring surgical repair increased the relative risk by 37-fold. There were no cases of meningitis following repair of long-standing CSF fistula or encephalocoele (0/26) and no cases following surgery for sinonasal tumors with skull base involvement (0/33). Conclusion For sella-centered pathologies, a single dose of intravenous co-amoxiclav (or teicoplanin) is associated with rates of meningitis comparable to those reported in the literature. Postoperative meningitis was significantly higher for extended, intradural transphenoidal approaches, especially when postoperative CSF leak occurred. Fastidious efforts to prevent postoperative CSF leak are crucial to minimizing risk of meningitis.

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Anterior Skull Base Meningioma: Surgical approach and complication avoidance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1733-9320 ◽

2022 ◽

Author(s):

Bhawan Nangarwal ◽

Jaskaran Singh Gosal ◽

Kuntal Kanti Das ◽

Deepak Khatri ◽

Kamlesh Singh Bhaisora ◽

...

Keyword(s):

Skull Base ◽

Tumor Resection ◽

Vascular Complications ◽

Good Alternative ◽

Anterior Skull Base ◽

Csf Leak ◽

Medical Complication ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Skull Base Meningioma

Background: Endoscopic endonasal approach (EEA) and keyhole transcranial approaches are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective: We compare tumor resection rates and complication profiles of EEA and supraorbital key hole approach (SOKHA) against conventional transcranial approaches (TCA). Methods: Fifty-four patients with ASBM [olfactory groove (OGM), n=19 and planum sphenoidale/tuberculum sellae (PS/TSM), n=35) operated at a single centre over 7 years were retrospectively analyzed. Results: The overall rate of GTR was higher in OGM (15/19, 78.9%) than PS-TSM group (23/35, 65.7%, p=0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death (n=1) following medical complication (TCA) and CSF leak requiring re-exploration (n=2, one each in TCA and EEA) accounted for the major complications in OGM. For the PS/TSM group, the GTR rates were 73.3% (n=11/15), 53.8% (n=7/13) and 71.4% (n=5/7) with TCA, EEA and SOKHA respectively. Seven patients (20%) of PS-TSM developed major postoperative complications including 4 deaths (one each in TCA, SOKHA and 2 in EEA group) and 3 visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PS-TSM especially if the tumor has encased intracranial arteries. Conclusions: No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma related problems. SOKHA may be a good alternative to TCA in selected PS-TSMs while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PS-TSM.

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Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas

Neurosurgical FOCUS ◽

10.3171/2018.1.focus17734 ◽

2018 ◽

Vol 44 (4) ◽

pp. E7 ◽

Cited By ~ 19

Author(s):

Malte Ottenhausen ◽

Kavelin Rumalla ◽

Andrew F. Alalade ◽

Prakash Nair ◽

Emanuele La Corte ◽

...

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

Anterior Skull Base ◽

Cribriform Plate ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Incision Size ◽

The Mean ◽

Skull Base Meningiomas

OBJECTIVEAnterior skull base meningiomas are benign lesions that cause neurological symptoms through mass effect on adjacent neurovascular structures. While traditional transcranial approaches have proven to be effective at removing these tumors, minimally invasive approaches that involve using an endoscope offer the possibility of reducing brain and nerve retraction, minimizing incision size, and speeding patient recovery; however, appropriate case selection and results in large series are lacking.METHODSThe authors developed an algorithm for selecting a supraorbital keyhole minicraniotomy (SKM) for olfactory groove meningiomas or an expanded endoscopic endonasal approach (EEA) for tuberculum sella (TS) or planum sphenoidale (PS) meningiomas based on the presence or absence of olfaction and the anatomical extent of the tumor. Where neither approach is appropriate, a standard transcranial approach is utilized. The authors describe rates of gross-total resection (GTR), olfactory outcomes, and visual outcomes, as well as complications, for 7 subgroups of patients. Exceptions to the algorithm are also discussed.RESULTSThe series of 57 patients harbored 57 anterior skull base meningiomas; the mean tumor volume was 14.7 ± 15.4 cm3 (range 2.2–66.1 cm3), and the mean follow-up duration was 42.2 ± 37.1 months (range 2–144 months). Of 19 patients with olfactory groove meningiomas, 10 had preserved olfaction and underwent SKM, and preservation of olfaction in was seen in 60%. Of 9 patients who presented without olfaction, 8 had cribriform plate invasion and underwent combined SKM and EEA (n = 3), bifrontal craniotomy (n = 3), or EEA (n = 2), and one patient without both olfaction and cribriform plate invasion underwent SKM. GTR was achieved in 94.7%. Of 38 TS/PS meningiomas, 36 of the lesions were treated according to the algorithm. Of these 36 meningiomas, 30 were treated by EEA and 6 by craniotomy. GTR was achieved in 97.2%, with no visual deterioration and one CSF leak that resolved by placement of a lumbar drain. Two patients with tumors that, based on the algorithm, were not amenable to an EEA underwent EEA nonetheless: one had GTR and the other had a residual tumor that was followed and removed via craniotomy 9 years later.CONCLUSIONSUtilizing a simple algorithm aimed at preserving olfaction and vision and based on maximizing use of minimally invasive approaches and selective use of transcranial approaches, the authors found that excellent outcomes can be achieved for anterior skull base meningiomas.

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Heterogeneity in Outcome Reporting in Endoscopic Endonasal Skull Base Reconstruction: A Systematic Review

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1714108 ◽

2020 ◽

Author(s):

Christina Dorismond ◽

Griffin D. Santarelli ◽

Brian D. Thorp ◽

Adam J. Kimple ◽

Charles S. Ebert ◽

...

Keyword(s):

Systematic Review ◽

Skull Base ◽

Meta Analysis ◽

Reporting Guidelines ◽

Csf Leak ◽

Cochrane Library ◽

Significant Heterogeneity ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

History Of

Abstract Objectives Presently, there are no standards for reporting outcomes of endoscopic endonasal skull base reconstruction (ESBR). This is problematic as a lack of consistent reporting makes synthesizing findings in systematic reviews and meta-analysis challenging. Thus, the aim of this study was to systematically review and describe the patterns of reporting outcomes in ESBR as a foundation for developing reporting guidelines. Study Design Present study is a systematic review. Methods Embase, PubMed, CINAHL, Cochrane Library, and Web of Science were searched for all publications with ≥25 patients and a focus on ESBR. The reporting patterns of each study's variables and outcomes were assessed. Results A total of 112 studies were included in the review. The most commonly reported demographic variables were the number of included patients (n = 112, 100%) and types of pathologies treated (n = 104, 92.9%). Meanwhile, the most routinely described preoperative variable was history of prior treatment (n = 48, 42.9%). Type of reconstruction was a commonly reported intraoperative variable (n = 110, 98.2%), though the rate of intraoperative cerebrospinal fluid (CSF) leak was noted in only 76 studies (67.9%). With regard to postoperative outcomes, postoperative CSF leak rate was routinely provided (n = 101, 90.2%), but reporting of other surgical complications was more inconsistent. Ultimately, of the 43 variables and outcomes reviewed, a median of 12 (range: 4–22) was reported in each study. Conclusions There is significant heterogeneity in the outcomes reported in studies relating to ESBR. This highlights the need for the development of standard reporting guidelines to minimize bias and improve interstudy comparability.

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Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years

World Neurosurgery ◽

10.1016/j.wneu.2015.12.105 ◽

2016 ◽

Vol 95 ◽

pp. 383-391 ◽

Cited By ~ 29

Author(s):

Anouk Borg ◽

Matthew A. Kirkman ◽

David Choi

Keyword(s):

Systematic Review ◽

Skull Base ◽

Skull Base Surgery ◽

Anterior Skull Base ◽

Endoscopic Endonasal ◽

The Past

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The Endoscopic Endonasal Management of Anterior Skull Base Meningiomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669463 ◽

2018 ◽

Vol 79 (S 04) ◽

pp. S300-S310 ◽

Cited By ~ 4

Author(s):

Federica Guaraldi ◽

Ernesto Pasquini ◽

Giorgio Frank ◽

Diego Mazzatenta ◽

Matteo Zoli

Keyword(s):

Skull Base ◽

Frontal Sinus ◽

Anterior Skull Base ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Skull Base Meningioma ◽

First Choice ◽

Tuberculum Sellae ◽

Skull Base Meningiomas

Introduction The endoscopic endonasal approach (EEA) might seem an “unnatural” route for intradural lesions such as meningiomas. The aim of this study is to critically revise our management of anterior skull base meningiomas to consider, in what cases it may be advantageous. Material and Methods Each consecutive case of anterior skull base meningioma operated on through an EEA or combined endoscopic–transcranial approach at our institution, between 2003 and 2017, have been included. Tumors were classified on the basis of their location and intra or extracranial extension. Follow-up consisted of an MRI (magnetic resonance imaging) and a clinical examination 3 months after the surgery and then repeated annually. Results Fifty-seven patients were included. The most common location was the tuberculum sellae (62%), followed by olfactory groove (14%), planum sphenoidale (12%), and frontal sinus (12%). Among these, 65% were intracranial, 7% were extracranial, and 28% both intra and extracranial. Radical removal was achieved in 44 cases (77%). Complications consisted in 10 CSF (cerebrospinal fluid) leaks (17.6%), 1 overpacking (1.7%), and 1 asymptomatic brain ischemia (1.7%). Visual acuity and campimetric deficits improved respectively in 67 and 76% of patients. Recurrence rate was of 14%. Conclusions EEA presents many advantages in selected cases of anterior skull base meningioma. However, it is hampered by the relevant risk of CSF leak. We consider that it could be advantageous for planum/tuberculum sellae tumors. Conversely, for olfactory groove or frontal sinus meningiomas, it can be indicated for tumors with extracranial extension, while its role is still debatable for purely intracranial forms as considering our surgical results, it could be advantageous for midline planum/tuberculum sellae tumors. Conversely, it can be of first choice for olfactory groove or frontal sinus meningiomas with extracranial extension, while its role for purely intracranial forms is still debatable.

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Chondro-osseous respiratory epithelial adenomatoid hamartoma of the nasal cavity (COREAH): A case report

Journal of Otolaryngology-ENT Research ◽

10.15406/joentr.2019.11.00429 ◽

2019 ◽

Vol 11 (3) ◽

pp. 175-179

Author(s):

Nikolopoulos Elias MD

Keyword(s):

Nasal Cavity ◽

Skull Base ◽

Anterior Skull Base ◽

Adult Patients ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Clinical Records

Objective: Determine the efficacy of the anterior skull base reconstruction in adult patients with intranasal meningoceles and meningoencephaloceles treated by endoscopic endonasal approach. Study design: Retrospective observational study of adult patients admitted to a tertiary hospital. Materials and methods: Intranasal meningocele was defined as a protrusion of meninges through a defect in the skull base forming a cyst filled with cerebrospinal fluid in the nasal cavity or paranasal sinuses. If the cyst had brain tissue it was called meningoencephalocele. The electronic clinical records of patients admitted with suspected of intranasal MC or MEC between January 2010 and December 2018 were reviewed. All patients treated by endoscopic endonasal approach were included. We excluded those cases with anterior skull base previous surgeries (iatrogenic or following tumoral resections), reconstruction with external surgical approaches and those who were less than 18 years old. Results: Intranasal MC was the most frequent lesion (6/5) and there was one patient with MEC (1/6). 5 cases were idiopathic and one patient had history of transnasal surgery. A total of 83,3% of the cases were primary surgeries and one patient had 3 prior MC surgeries. Only in four of them (66,6%) the lesion location was detected by at least one of the studies (CT, MRI and/or endoscopy). We performed a multilayer closure technique in all patients. During the immediate postoperative period, one patient had acute meningitis. One patient had a CSF leak recurrence 4 months after surgery. The success rate of the reconstructions performed by endonasal approach was 83.33% (5/6). The average follow-up of the patients was 15 months. Conclusion: The effectiveness of the anterior skull base reconstruction in adult patients with meningoceles and meningoencephaloceles performed by endoscopic endonasal approach in our series was 83.33% (5/6). This procedure is currently the gold standard due to its high efficacy and low morbidity. According to current studies, it is recommended to perform the reconstruction with a multilayer technique.

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Anterior Skull Base Tumors and Surgery

10.2310/ot.7057 ◽

2021 ◽

Author(s):

Judd H. Fastenberg ◽

Gurston G. Nyquist ◽

Blair M. Barton

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Sinus Surgery ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Dural Repair ◽

Endoscopic Techniques ◽

Anterior Cranial Base ◽

Tissue Flaps ◽

Skull Base Defects

Anterior skull base surgery requires intimate knowledge of a highly complex anatomic region containing critical neurovascular structures. A wide array of pathologies can occur along the anterior cranial base, including meningiomas, esthesioneuroblastomas, pituitary adenomas, craniopharyngiomas, chondrosarcomas, and chordomas. Advancements in endoscopic sinus surgery have allowed many of these tumors to be effectively treated via an endoscopic endonasal technique. This approach obviates the need for large incisions causing cosmetic deformity, improves magnification of the surgical field, and offers a direct path to lesions thus avoiding retraction of structures such as the brain and nerves. Surgeons must understand the limitations of endoscopic techniques and consider open or combined open and endoscopic approaches when appropriate. Reconstructive anterior skull base techniques vary depending on the size and location of defects, along with factors such as intracranial pressure and patient co-morbidities. Large skull base defects require multilayer reconstruction that include a watertight primary dural repair with either synthetic or autologous tissue, followed by local vascularized tissue flaps. This review contains 8 figures, 2 videos, 4 tables and 33 references Key words: Anterior skull base, meningioma, esthesioneuroblastoma, chordoma, pituitary, CSF leak, nasosptal flap, dural repair, expanded endonasal approaches, endoscopic surgery

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Endoscopic endonasal repair of anterior skull base non-traumatic cerebrospinal fluid leaks, meningoceles, and encephaloceles

Journal of Neurosurgery ◽

10.3171/2009.10.jns08986 ◽

2010 ◽

Vol 113 (5) ◽

pp. 961-966 ◽

Cited By ~ 68

Author(s):

Gurston G. Nyquist ◽

Vijay K. Anand ◽

Saral Mehra ◽

Ashutosh Kacker ◽

Theodore H. Schwartz

Keyword(s):

Skull Base ◽

Frontal Sinus ◽

Anterior Skull Base ◽

Cribriform Plate ◽

Csf Leak ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Closure Rate ◽

Endoscopic Endonasal ◽

Csf Leaks

Object The endoscopic endonasal approach has become the preferred technique for CSF leak and encephalocele repair of the anterior skull base. The purpose of this study is to identify patient characteristics; review adjunctive perioperative treatments, reconstruction techniques, and outcomes; and identify risk factors for failure in patients undergoing endoscopic endonasal repair of anterior skull base CSF leaks and encephaloceles. Methods This is a prospective observational study of patients undergoing endoscopic endonasal repair of a CSF leak between October 2004 and May 2009. Twenty-eight consecutive patients underwent 32 procedures. Twenty-two of the patients were women, which represents a statistically significant trend toward the female sex (p < 0.05). The average body mass index (33.9) was significant for obesity. The origin of the skull base defect included the cribriform plate (in 9 cases), fovea ethmoidalis (in 7), combined fovea ethmoidalis/cribriform plate (in 2), lateral sphenoid sinus (in 6), sella (in 4), clivus (in 3), and frontal sinus (in 1). Results The overall endonasal closure rate was 93.8% (30 of 32 procedures). One failure occurred due to overaggressive postoperative debridement, while the other recurred along the posterior wall of the frontal sinus, and endoscopic repair would have occluded the recess. Conclusions The endoscopic endonasal approach for the treatment of CSF leaks and encephaloceles of the anterior skull base is the preferred method of repair in the vast majority of cases. The authors' 93.8% closure rate in a variety of anatomical locations compares favorably with the transcranial approach and echoes the results of other endoscopic series.

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