Protection of the Cranial Base after Endoscopic Transsphenoidal Skull Base Surgery

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

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Expanding Cranial Base Surgery

Otolaryngology ◽

10.1016/s0194-5998(05)80353-5 ◽

1995 ◽

Vol 112 (5) ◽

pp. P136-P136

Author(s):

Ivo P. Janecka ◽

Daniel Nuss ◽

David Vernick ◽

Gerhard Oberascher

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Base ◽

Imaging Modalities ◽

Educational Objectives ◽

Congenital Lesions ◽

New Approaches ◽

Cranial Base Surgery ◽

Technical Principles

Educational objectives: To determine the applicability and become familiar with technical principles of new approaches to skull base for oncologic as well as congenital lesions and to understand the current advances in imaging modalities as well as current achievable outcome with skull base surgery.

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Surgery of the Skull Base for Head and Neck Neoplasms

Otolaryngology ◽

10.1016/s0194-5998(05)80206-2 ◽

1995 ◽

Vol 112 (5) ◽

pp. P88-P88

Author(s):

Paul J. Donald ◽

Bernard M. Lyons ◽

Joao J. Maniglia

Keyword(s):

Head And Neck ◽

Skull Base ◽

Head And Neck Neoplasms ◽

Skull Base Surgery ◽

Cranial Base ◽

Posterior Cranial Fossa ◽

Educational Objectives ◽

Cranial Fossa ◽

Relationship Of ◽

The Relationship

Educational objectives: To understand the relationship of deep facial structures to the cranial base and the pertinent intracranial anatomy; to perform the comprehensive workup required by skull base surgery patients; and to acquire a working knowledge of the basic skull base procedures in the anterior, middle, and posterior cranial fossa.

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Long-term impact of pediatric endoscopic endonasal skull base surgery on midface growth

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.8.peds18183 ◽

2019 ◽

Vol 23 (4) ◽

pp. 523-530 ◽

Cited By ~ 6

Author(s):

Wendy Chen ◽

Paul A. Gardner ◽

Barton F. Branstetter ◽

Shih-Dun Liu ◽

Yue Fang Chang ◽

...

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Base ◽

Early Surgery ◽

Endoscopic Endonasal ◽

Anterior Maxilla ◽

Surgery Group ◽

Significant Difference

OBJECTIVECranial base development plays a large role in anterior and vertical maxillary growth through 7 years of age, and the effect of early endonasal cranial base surgery on midface growth is unknown. The authors present their experience with pediatric endoscopic endonasal surgery (EES) and long-term midface growth.METHODSThis is a retrospective review of cases where EES was performed from 2000 to 2016. Patients who underwent their first EES of the skull base before age 7 (prior to cranial suture fusion) and had a complete set of pre- and postoperative imaging studies (CT or MRI) with at least 1 year of follow-up were included. A radiologist performed measurements (sella-nasion [S-N] distance and angles between the sella, nasion, and the most concave points of the anterior maxilla [A point] or anterior mandibular synthesis [B point], the SNA, SNB, and ANB angles), which were compared to age- and sex-matched Bolton standards. A Z-score test was used; significance was set at p < 0.05.RESULTSThe early surgery group had 11 patients, with an average follow-up of 5 years; the late surgery group had 33 patients. Most tumors were benign; 1 patient with a panclival arteriovenous malformation was a significant outlier for all measurements. Comparing the measurements obtained in the early surgery group to Bolton standard norms, the authors found no significant difference in postoperative SNA (p = 0.10), SNB (p = 0.14), or ANB (0.67) angles. The S-N distance was reduced both pre- and postoperatively (SD 1.5, p = 0.01 and p = 0.009). Sex had no significant effect. Compared to patients who had surgery after the age of 7 years, the early surgery group demonstrated no significant difference in pre- to postoperative changes with regard to S-N distance (p = 0.87), SNA angle (p = 0.89), or ANB angle (p = 0.14). Lesion type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group.CONCLUSIONSThough our cohort of patients with skull base lesions demonstrated some abnormal measurements in the maxillary-mandibular relationship before their operation, their postoperative cephalometrics fell within the normal range and showed no significant difference from those of patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

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Primary dural closure and anterior cranial base reconstruction using pericranial and nasoseptal multi-layered flaps in endoscopic-assisted skull base surgery

Acta Neurochirurgica ◽

10.1007/s00701-014-2174-x ◽

2014 ◽

Vol 156 (10) ◽

pp. 1911-1915 ◽

Cited By ~ 11

Author(s):

Ryosuke Tomio ◽

Masahiro Toda ◽

Toshiki Tomita ◽

Masaki Yazawa ◽

Maya Kono ◽

...

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Base ◽

Dural Closure ◽

Anterior Cranial Base

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138 Endoscopic Endonasal Skull Base Surgery in Pediatric Patients and Impact on Midface Growth

Neurosurgery ◽

10.1093/neuros/nyx417.138 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 232-232

Author(s):

Wendy Chen ◽

Shih-Dun Liu ◽

Barton F Branstetter ◽

Yue-Fang Chang ◽

Lindsay A Schuster ◽

...

Keyword(s):

Skull Base ◽

Pediatric Patients ◽

Skull Base Surgery ◽

Score Test ◽

Growth Period ◽

Cranial Base ◽

Tumor Type ◽

Endoscopic Endonasal ◽

Significant Difference ◽

Maxilla And Mandible

Abstract INTRODUCTION Cranial base development plays a large role in anterior and vertical maxillary growth through age 7, and the effect of early endonasal cranial base surgery on midface growth is unknown. We present our experience with pediatric endoscopic endonasal surgery and long-term midface growth. METHODS This is a retrospective review (2000-2016). Pediatric patients were grouped by age at first endoscopic endonasal skull base surgery (<7 yo and >7 yo). Included patients had both pre- and post-operative (>1 yr) imaging. Radiologists performed measurements (Sella-Nasion distance and angles from S-N to maxilla and mandible (SNA, SNB, ANB)), which were compared to age- and sex-matched Bolton standards. Z score test was used; significance was set at P < 0.05. RESULTS >The <7 yo group had 11 patients, averaging follow-up of 5 yrs; the >7 yo group had 33 patients. Most tumors were benign; one patient with a panclival AVM was a significant outlier for all measurements. Comparing the <7 yo group to Bolton standard norms, there was no significant difference in post-operative SNA (P = 0.10), SNB (P = 0.14), or ANB (0.67). SN distance was reduced both pre- and post-operatively (SD = 1.5, P = 0.01 and P = 0.009). Sex had no significant effect. Compared to patients who had surgery in the >7 yo group, the <7 yo group demonstrated no significant difference in pre- to post-operative changes with regard to S-N (P = 0.87), SNA (P = 0.89), and ANB (P = 0.14). Tumor type (craniopharyngioma, angiofibroma, and other types) had no significant effect in either age group. CONCLUSION Though our cohort of patients with skull base tumors demonstrate some abnormal measurements before their operation, their post-operative cephalometrics fall within normal standard deviations and generally have no significant difference compared to patients who underwent operations at an older age. Therefore, there appears to be no evidence of impact of endoscopic endonasal skull base surgery on craniofacial development within the growth period studied.

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Porous polyethylene implant for cranioplasty and skull base reconstruction

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.3.14 ◽

2004 ◽

Vol 16 (3) ◽

pp. 1-5 ◽

Cited By ~ 24

Author(s):

James K. Liu ◽

Oren N. Gottfried ◽

Chad D. Cole ◽

William R. Dougherty ◽

William T. Couldwell

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Operating Time ◽

Cranial Base ◽

Surgical Reconstruction ◽

Risk Of Infection ◽

Porous Polyethylene ◽

Skull Base Reconstruction ◽

Cosmetic Results ◽

Porous Polyethylene Implant

Object Cranial reconstruction after skull base surgery is important for restoration of function and cosmesis. The authors describe their experience with the Medpor porous polyethylene implant for cosmetic cranioplasty and reconstruction after skull base surgery. Methods Medpor, a biocompatible implant, is flexible and can be contoured to facilitate surgical reconstruction of small to medium (< 8 cm) convexity or cranial base defects resulting from a variety of skull base approaches. This method provides similar cosmetic results to standard alloplast cranioplasty while decreasing operating time. The porous nature of the material allows ingrowth of soft tissue and bone to increase implant strength and decrease the risk of infection. This material can also be used safely in reconstruction of the cranium and skull base adjacent to the paranasal sinuses. Conclusions The authors have used the Medpor porous polyethylene implant in 611 standard cranial and skull base procedures and have achieved excellent cosmetic results and no implant-related complications.

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Jugular Foramen Tumors

Otorhinolaryngology Clinics - An International Journal ◽

10.5005/jp-journals-10003-1050 ◽

2011 ◽

Vol 3 (1) ◽

pp. 15-23 ◽

Cited By ~ 1

Author(s):

C Rayappa

Keyword(s):

Skull Base ◽

Cranial Nerve ◽

Skull Base Surgery ◽

Cranial Nerves ◽

Radical Resection ◽

Jugular Foramen ◽

Cranial Base ◽

Lower Cranial Nerve ◽

Radiological Features ◽

Lower Cranial Nerves

ABSTRACT Jugular foramen tumors are rare cranial base lesions that present diagnostic and management difficulties. Paragangliomas were the most frequent lesions, followed by schwannomas and meningiomas. These tumors have characteristic radiological features. Radical resection of these tumors with preservation of the lower cranial nerves is the treatment of choice. Despite the advances in skull base surgery, new postoperative lower cranial nerve deficits still represent a challenge.

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Expanded endoscopic endonasal transcribriform approach for resection of anterior skull base olfactory schwannoma

Neurosurgical FOCUS ◽

10.3171/2012.v3.focus11300 ◽

2012 ◽

Vol 32 (Suppl1) ◽

pp. E3 ◽

Cited By ~ 6

Author(s):

James K. Liu ◽

Jean Anderson Eloy

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Tumor Resection ◽

Cranial Base ◽

Anterior Skull Base ◽

Endoscopic Endonasal ◽

Olfactory Groove ◽

Anterior Cranial Base ◽

Ventral Skull Base ◽

Brain Retraction

Anterior skull base (ASB) schwannomas are extremely rare and can often mimic other pathologies involving the ASB such as olfactory groove meningiomas, hemangiopericytomas, esthesioneuroblastomas, and other malignant ASB tumors. The mainstay of treatment for these lesions is gross-total resection. Traditionally, resection for tumors in this location is performed through a bifrontal transbasal approach that can involve some degree of brain retraction or manipulation for tumor exposure. With the recent advances in endoscopic skull base surgery, various ASB tumors can be resected successfully using an expanded endoscopic endonasal transcribriform approach through a “keyhole craniectomy” in the ventral skull base. This approach represents the most direct route to the anterior cranial base without any brain retraction. Tumor involving the paranasal sinuses, medial orbits, and cribriform plate can be readily resected. In this video atlas report, the authors demonstrate their step-by-step techniques for resection of an ASB olfactory schwannoma using a purely endoscopic endonasal transcribriform approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/NLtOGfKWC6U.

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