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Surgery oftheAnterior Skull Base
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ChristianStephanBetz
36
Introduction
In the clinical reality of the otorhinolaryngologist, the skull base is divided into the anterior and
the lateral skull base. Whereas the former refers
to the parts of the skull base that abut the paranasal sinus system, the latter lie adjacent to the temporal bone. From anterior to posterior, the medial
anterior skull base is thus represented by the posterior wall of the frontal sinus, the cribriform
plate, the sphenoid planum, the sella and the
clivus.
Anterior skull base surgery serves the purpose
to resect neoplastic or non-neoplastic lesions that
involve the skull base or to act as a portal for
intracranial lesions. Neoplastic entities include
sinonasal tumours with extension into the skull
base and intracranial tumours that affect the skull
base from above. The latter includes meningiomas, especially when arising within the olfactory
groove, craniopharyngiomas and distant metasta-
ses of various malignant tumour entities. Nonneoplastic lesions of the anterior skull base
comprise a variety of different pathologies, but
meningoceles and meningoencephaloceles are
the most prominent.
Anterior Skull Base Surgery
With its multitude of important vascular and neural structures in a conned anatomical space, as
well as its rather remote location in the centre of
the head, the anterior skull base is a challenging
area for surgical interventions.
The safe surgical management of patients with
anterior skull base pathologies requires a thorough, comprehensive, anatomical, functional,
pathological and physiological knowledge of this
complex region. Anterior skull base surgery is
usually reserved for experienced surgeons and
should both be planned and performed by an
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 28690- 2_36.
C. S. Betz (*)
Department of Otorhinolaryngology, University
Medical Centre Hamburg-Eppendorf,
Hamburg, Germany
e-mail: c.betz@uke.de
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. C. Swift et al. (eds.), Contemporary Rhinology: Science and Practice,
https://doi.org/10.1007/978-3-031-28690-2_36
467
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C. S. Betz
interdisciplinary team (neurosurgeons and otorhinolaryngologic surgeons ± representatives
from other specialties such as maxillofacial surgery or orbital surgery). For neoplastic indications, multidisciplinary tumour boards
[multidisciplinary teams (MDTs)] with a head
and neck or a neurooncological focus might sufce as a proper platform to discuss these cases,
but they may miss out on equally challenging
non-oncological cases. Regular interdisciplinary
skull base meetings of a dedicated skull base
team have become the gold standard for the socalled skull base centres in many countries, even
though an appropriate international standardization has not yet been undertaken.
A proper and thorough assessment of the cases
before surgical treatment is thereby at least as
important as the operation itself. The following
points need special consideration:
• Surgery versus ‘watch & scan’ or other treat-
ment modalities: Not all anterior skull base
lesions need to be addressed surgically as ther-
apy of choice. For example, some benign neo-
plastic lesions (e.g. osteomas) can be followed
via imaging, and some other lesions (e.g. cer-
tain types of sarcomas) might do better with
primary conservative treatment measures.
• Complete resection vs. gross total resection or
subtotal resection: The understanding of the
targeted surgical resection margin for malig-
nant neoplastic pathologies differs between
the neurosurgeon and the otorhinolaryngolo-
gist. Whereas the former usually aims at a
gross total resection (i.e. no tumour enhance-
ment in postoperative imaging) whilst avoid-
ing the so-called ‘eloquent’ (functionally
important) areas of the brain, the otorhinolar-
yngologist is generally aiming for a clear
resection margin of at least 5mm in all direc-
tions. The aims of gross resection, total clear-
ance or subtotal resection need to be carefully
considered during operative planning. The
surgical plan will also impact on adjuvant
therapy and prognosis in oncological cases.
• Proximity to vital structures: Pathological
skull base lesions can encroach or lie adjacent
to vital anatomical structures, and lesions may
surround or invade these structures. The oper-
ability of the lesion needs to be carefully considered with regard to the severity of risk,
intent to cure, postoperative morbidity and
mortality. The most prominent of these structures are the internal carotid arteries, the neurovascular structures of the orbital apex and
the brainstem (including the basilar artery and
the cranial nerves originating from it).
As for all other operative areas, surgery of the
anterior skull base can be broken down into three
distinct parts:
– Approach or access
– Tumour resection
– Closure of skull base defect and
reconstruction
All of these components need to be considered
and discussed in detail prior to surgery, ideally in
the dedicated skull base MDT. Operative planning is of paramount importance and inadequate
planning cannot always be compensated for at
the time of surgery.
Surgery inevitably creates a breach of the barrier between the sterile intracranial and the
‘clean-contaminated’ (para)nasal space, irrespective of the approach. This results in a considerable risk of infective complications. A suitable
prophylactic antibiotic is essential and should be
planned before surgery. Cefuroxime or an agent
with a similar spectrum is recommended, commencing with induction, and continued preoperatively for up to 24h following surgery [1].
The following paragraphs describe the traditional open routes to access the skull base, novel
endoscopic routes and combined approaches.
Open-Approach Surgery
Approach
Transfacial Approaches
These approaches are often suitable and sufcient for pathologies involving but not extending
beyond the anterior skull base.
For benign neoplasms that may involve the
anterior skull base, such as juvenile angiobroma
or inverted papilloma (and potentially a small,
well-dened group of malignancies), the midfa-
36 Surgery oftheAnterior Skull Base
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469
cial degloving approach is advocated as the open
approach of choice as it leaves no facial scars. The
exposure of the anterior skull base offered by this
approach is somewhat inferior to that of the lateral
rhinotomy approach, but it is superior with regard
to accessibility of the pterygopalatine fossa and
the medial aspect of the infratemporal fossa.
For malignancies, a lateral rhinotomy is the
preferred transfacial route of access. This
approach can be combined with additional incisions, for example:
• An upper lip-split (‘Weber-Ferguson’
approach) if the lower maxilla is involved
• A supraorbital incision (‘Lynch’ incision) if the
posterior wall of the frontal sinus is involved
• An infraorbital incision (‘Dieffenbach’ inci-
sion) if the infraorbital rim or the zygomatic
root is involved
A temporary partial maxillectomy +/- removal
of the anterior wall of the frontal sinus is recommended as long as the pathology does not involve
the previously mentioned structures. This additional access facilitates wide access to the maxillary, ethmoidal and sphenoidal sinuses, the
medial aspects of the orbits and the anterior skull
base, extending back to the sphenoid planum.
The osteotomies, as well as the extent of bone
removal, need to be adapted according to the
extent of the individual pathology and lesion.
Craniofacial and Subcranial Approaches
For pathologies that show an intracranial extension beyond the skull base, the so-called craniofacial approach as well as the subcranial approach
are standard procedures to gain excellent access
to this complex area [3].
The craniofacial approach (Fig. 36.1) combines a transfacial approach for access to the
skull base from below with a frontal craniotomy
for skull base exposure from above:
– Transfacial approach: usually a Weber-
Ferguson incision, some form of maxillec-
tomy and a spheno-ethmoidectomy.
– Frontal craniotomy:
Incision: usually a bicoronal incision, less
common a buttery incision. The bicoronal
incision has several advantages over a butter-
y incision, such as avoidance of an obvious
facial scar, and improved access for intracra-
nial resection, and excellent access to a large,
well-vascularized pericranial ap for
reconstruction.
Dimensions: vertical dimension—glabella to
several centimetres above the superior edge of
the frontal sinus; horizontal dimension—mid-
pupillary line bilaterally.
Fig. 36.1 Illustration of the craniofacial approach (left:
access to the skull base from below via lateral rhinotomy
and partial maxillectomy; right: access to the skull base
from above via bicoronal incision and frontal craniotomy). Originally published in [3]; reprint permission
granted by Springer
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Fig. 36.2 Illustration of the subcranial approach (removal
of fronto-naso-orbital bone segment following bicoronal
incision). Originally published in [3]; reprint permission
granted by Springer
The subcranial approach (Fig. 36.2) was originally described by Raveh as a means of treating
anterior skull base fractures [4]. It offers a single access approach providing a simultaneous
view of the skull base from above and below. A
fronto-naso-orbital bone segment (+/- inclusion
of the posterior wall of the frontal sinus) is temporarily removed following careful dissection
of the supraorbital bundles and placement of
adequate osteotomies. The size of the bone segment is determined individually by the actual
disease.
Resection
Following the (sometimes cumbersome) open
access to the skull base lesion, curative resection, if possible, is traditionally ‘en bloc’. If enbloc resection is not possible, excision is
performed in two or more sections, but special
care is taken to orientate each section to enable
the pathologist to verify the completeness of
resection and tumour margins. For malignant
tumours, the safety margin should ideally be
5mm in all directions.
It is common understanding, however, that the
sacrice of vital and functioning structures (such as
eloquent regions of the brain or the optic nerve) in
C. S. Betz
close proximity to the tumour needs to be weighed
against the gain in oncological outcome measures
such as tumour-specic survival. Histopathology
of intraoperative frozen sections of resection margins can be really helpful to ascertain the completeness of resection. However, it can be hindered by
(a) selection of specimens and (b) reliability of the
reports, especially in pathologies that are difcult
to diagnose. For malignant tumours invading or
extending beyond the dura, intraoperative dural
margin assessment is essential.
Reconstruction
A breach of the dura can lead to potentially lifethreatening postoperative complications. The
prime objective of all reconstructive measures
should be a watertight dural seal, thus reestablishing an effective barrier between the sterile intracranial and the ‘clean-contaminated’
endonasal space.
The need to reconstruct the supporting tissues
of the skull base should be considered but is often
unnecessary. On occasions where support seems
mandatory, split calvarial bone, bone cement,
cartilage, titanium mesh or PDS plates may be
used. However, the nasal cavity surface of the
graft should always be covered by a soft tissue
layer (ideally perfused) to prevent necrosis or
infection.
In open transfacial approaches with sole exposure from below, the dural seal is usually accomplished by using a combination of both autologous
(e.g. facia lata, nasoseptal ap) and fabricated
material in layers, which are applied in both an
underlay and an overlay technique. In open craniofacial or subfrontal approaches with good exposure, a watertight dural seal can usually be
accomplished via primary closure or by suturing
in either articial (collagen-based) dural replacement material or facia lata, respectively. In larger
defects, an additional onlay graft from below (such
as a nasoseptal ap) may add to the stability of the
closure. In very large defects or recurrent CSF
leaks in pre-irradiated patients, free aps can be
used as an ultimate means of closure. In these
cases, de-epithelialized radial forearm aps are
most used.
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471
The nasal cavity is loosely packed with nasal
tampons for 3–5days to support the reconstruction from below during the postoperative phase.
The author prefers to interpose a layer of gelatin
sponge between the packing and the reconstruction to prevent disturbing the repair when the
packing is removed.
As for closure of the access of the frontal craniotomy in craniofacial or subfrontal approaches,
the preserved, well-vascularized pericranial ap
is wrapped around the frontal/fronto-naso-orbital
bone segment. The posterior wall of the frontal
sinus is removed, thus ‘cranializing’ the sinus
cavity. The bone segment is then reattached to the
facial bones with titanium plates.
Postoperatively, the patient should have partial bed rest (toilet visits only) with a 30° elevated
upper body, stool softeners and prophylactic antithrombotic treatment. A perioperative lumbar
drain is not necessary or recommended in most
patients. Postoperative imaging of the head
should be considered should neurological symptoms or signs arise.
Endoscopic Approach Surgery
Approach andResection
There have been tremendous developments with
endoscopic techniques and equipment over recent
years, such as the extended range of surgical
instruments, developments of reconstructive
methods specically designed for transnasal
approaches, improvements of navigation assistance and neurophysiological monitoring.
Transnasal endoscopic approaches have evolved
over the last two decades to become a viable
alternative to transnasal microscopic approaches
such as pituitary adenoma surgery and to traditional open approaches to the anterior skull base
for a selected range of cases.
Transnasal endoscopic approaches of skull
base lesions that extend into or beyond the dura:
• are typically performed jointly by a team
approach consisting of an otolaryngologist
experienced in endoscopic skull base surgery
and an endoscopically trained neurosurgeon
• can almost always be subdivided into three
distinct phases:
– Purely endonasal phase, performed by
otorhinolaryngologist
– Interdisciplinary skull base/intracranial
phase
– Transnasal closure, performed by otorhino-
laryngologist or interdisciplinary surgeon
The learning curve has been shown to follow
quite a shallow curve, and to avoid unwanted outcomes, a stable interdisciplinary team that operates regularly together is recommended. Such a
team can then slowly increase the level of complexity of the cases addressed [5].
As the indications for purely transnasal
approaches are still somewhat controversial
and a matter of debate, it will be much more
helpful for the reader to understand the most
important contraindications for such a course
of action (Table36.1):
Whilst open approaches offer a wide access
that facilitates en bloc resections and conventional techniques of reconstruction, endoscopic
approaches typically provide no more than a narrow corridor to the area of concern. They have
thus created the need for a true ‘rethinking process’ of traditional surgical principles.
Similar to transnasal resections of tumours
that do not affect the skull base, transnasal endoscopic surgery of skull base tumours inevitably
results in ‘piecemeal’ rather than en-bloc resections. This, however, does not seem to negatively
affect oncological outcome measures [6] so long
as the most important oncological principles are
respected. Margins should be kept to safe limits
Table 36.1 Contraindications to transnasal endoscopic
approaches to the skull base
• Invasion of orbital contents requiring orbital
exenteration
• Involvement of the skull base lateral to the medial
orbital wall (some authors suggest mid-orbit)
• Invasion of the anterior wall of the frontal and/or
maxillary sinus
• Invasion of the nasal bones
• Involvement of the facial skin
• Important neurovascular structures (e.g. optic
nerve) crossing the path of the chosen corridor
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C. S. Betz
wherever possible and checked by frozen-section
margin assessments when appropriate.
The description and classication of the different corridors that are commonly used in transnasal endoscopic skull base surgery today are
mostly an achievement of the skull base group at
University of Pittsburgh Medical Center (UPMC)
[7–9]. They have dened the corridors (Fig.36.3)
as follows:
Sagittal plane: the midline axis from anterior to
posterior, which is highly amenable for endo-
scopic approaches.
Coronal planes (CP): the lateral extensions to
both sides which pose much more difcult
tasks for the operating surgeons. As this would
exceed the scope of this book, the coronal
planes are not addressed further in this
chapter.
The different approaches in the sagittal plane
are thereby termed as follows:
Fig. 36.3 Illustration of the sagittal plane as well as the
coronal planes in transnasal endoscopic anterior skull
base surgery (TC transcribriform, TP/T transplanum/
transtuberculum, TS transsellar, TC transclival, TO transodontoid, CP-AF coronal plane to the anterior cranial
fossa, CP-MF coronal plane to the middle cranial fossa,
CP-PF coronal plane to the posterior cranial fossa).
Originally published in [10]; reprint permission granted
by Rockwater, Inc.
• Transcribriform (TC): This approach is mostly
used for neoplastic lesions of the nasal cavity
and/or paranasal sinuses affecting the anterior
skull base with limited lateral extension.
Olfactory neuroblastomas might serve as perfect examples of such lesions, as they are usually conned to the midline (Fig.36.4, Video
36.1). The same might be true for small olfactory groove meningiomas with limited lateral
extension. Similarly, benign and malignant
tumours of the paranasal sinuses that reside
mostly in the midline are rated as ideal candidates for transcribriform endoscopic resection.
• Transplanum/transtuberculum (TP/T): This
approach is recommendable for the resection
of craniopharyngiomas/Rathke cleft cysts,
large pituitary macroadenomas with considerable suprasellar extension and a carefully
selected subgroup of tuberculum sellae and
planum meningiomas.
• Transsellar (TS): This approach has become
the preferred route for many surgeons for the
resection of pituitary adenomas, as the endoscope is superior to the microscope with regard
to visualization of the target area (Fig.36.5),
thus minimizing the risk of postoperative pituitary dysfunction [11]. Even though it seems
likely that the rate of (gross) total resections
should also be higher for the endoscopic
approach, this has not been proven to date.
• Transclival (TC): This corridor is used for the
removal of various pathological entities that
lie anterior to the brainstem, with clival chordomas being the most prominent.
• Transodontoid (TO): This approach is the
most posterior one in the sagittal plane, reaching the craniocervical junction. The most relevant indications for it include bulbomedullary
compression caused by basilar invagination or
an os odontoideum (odontoid peg displacement) in rheumatoid arthritis.
In contrast to open-access surgery, transnasal
skull base surgery is best performed with a special set of equipment including:
• A set of surgical instruments dedicated to
transnasal skull base surgery (i.e. longer, ner
ab
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473
Fig. 36.4 Example of a purely transnasal, endoscopic
transcribriform resection of a T3 recurrent olfactory neuroblastoma (left: preoperative MRI, middle: intraopera-
Fig. 36.5 Illustration of the eld of view during endoscopic (left) and microscopic visualization (right) of the sellar
region
versions of the instruments developed for paranasal sinus surgery and instruments designed
especially for transnasal skull base surgery).
• A set of surgical instruments for achieving
haemostasis (a transnasal applicator for haemostatic clips, ne bipolar systems that are
tive image following resection of tumour ((1 Falx, 2 dural
margins, 3 frontal lobes, 4 resected olfactory bulbs) right:
postoperative MRI)
• A navigation system (optical or electromagnetical) that allows pre-planning of the procedure and intraoperative guidance.
• A high-resolution endoscopic camera system
that allows for a detailed intraoperative
visualization.
not hindered by the narrow nasal entrance).
• A transnasal burr (± shaver) system with
straight and curved blades and with integrated
rinsing and suction.
• A foot-pedal operated saline-wash cleaning
The surgical procedure itself is highly dependent on the individual features of the lesion that
needs to be removed. However, some characteristic steps need to be followed:
system for the endoscopic tip.
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C. S. Betz
• If a nasoseptal ap will/might be needed for
reconstruction (please see below), a ap
should be raised at the beginning of the surgical procedure and is then placed (‘parked’) in
the nasopharynx for later usage.
• The next stage is to remove, if present, the
endonasal portion of the disease whilst maintaining haemostasis and controlling the blood
supply relevant to the chosen corridor, such as
clipping of the anterior and posterior ethmoidal
arteries bilaterally in a transcribriform
approach.
• Depending on the location and size of the lesion
that needs to be addressed, the procedure may
require a bi-nostril approach; to achieve this,
parts of the (remaining) septum are resected
and sacriced. This is followed by surgical definition of the borders for resection of the bony
skull base. For example, during a transcribriform resection, the anterior border is the transition zone between the posterior wall of the
frontal sinus and the cribriform plate (visualized by performing a Draf Type III procedure),
the lateral borders are the foveae ethmoidalis
(visualized by a radical total ethmoidectomy),
and the posterior border is the transition zone of
the cribriform plate and the sphenoid plate
(visualized by a complete removal of the anterior wall of the sphenoid sinus). The bony skull
base dened by these borders is then carefully
removed using a coarse diamond burr, and the
dura is visualized.
• For lesions that do not extend into or beyond
the dura, the bony skull base (including rest of
the lesion) is carefully removed followed by a
reconstruction (see below).
• For all other lesions, the procedure now
becomes a truly interdisciplinary one, and it is
further performed using a three- or even fourhand technique. This means that the endoscope
(± a tool for suction) is held by the one surgeon, whereas the other proceeds with the
bimanual resection. Following dural incisions
around the lesion, the intradural part of the
procedure ensues, which is again highly individualized. It encompasses the (frozen section
proven) resection of all intracranial disease
whilst at best preserving vessels and brain
tissue.
Reconstruction
As for open approaches, a watertight dural seal
also needs to be accomplished in transnasal skull
base surgery, whilst the placement of supporting
tissue is usually not needed.
In those cases when the dura is exposed but
not incised, or where areas of dehiscence are very
limited, articial material such as Tachosil®
(Corza Health, Inc.) applied in an overlay technique in layers might sufce.
For all cases where a dural resection has
taken place, the nasoseptal ap [12] has become
the ‘work-horse’ for reconstruction in most centres. The nasoseptal ap, as well as other, less
commonly used vascularized aps, is placed as
a component part of a multi-layer closure that
may, for example, include a fascia lata as an
underlay graft, Tachosil® (Corza Health, Inc.)
as an overlay graft and the nasoseptal ap as an
onlay graft. The principle of multilayer closure
has signicantly reduced the rate of postoperative CSF leaks in transnasal skull base surgery,
achieving leak-free closure to a level comparable to open- approach surgery [13].
Fat tissue or fascia lata alone or in combination might sufce for a selected group of cases in
the clival and sella region.
Following reconstruction, the nasal cavity is
packed for 3–5days according to the recommendation given in open-approach surgery. Special
care is undertaken to assure that the reconstruction is neither disrupted or displaced during packing nor compressed to a degree that compromises
the perfusion of the vascularized ap.
Postoperative recommendations are similar to
those for open-approach surgery.
Should there be a high risk of a postoperative
CSF leak, as may occur in patients with an
intraoperative ‘high-ow’ leak, a postoperative
lumbar drain is recommended. The lumber drain
should be set with a ow of 10mL/h for 72h. This
has been shown to reduce the rate of CSF leaks
signicantly in a prospective randomized trial [14].
Combined Approach Surgery
Over the last decade, combined approaches (open
and transnasal) have become increasingly more
36 Surgery oftheAnterior Skull Base
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popular amongst skull base surgeons and may
sometimes be considered the best option for a case.
For example, tumours of the skull base with an
extension both intracranially and beyond the medial
orbital wall may qualify for a combination of a craniotomy approach (for a resection of the supraorbital and the intracranial part) and an endoscopic
approach (for the resection of the endonasal parts).
Summary ofAreas ofControversy
or Uncertainty
Due to the complex preconditions in a challenging anatomical area and the multitude of different
pathologies that need to be addressed, anterior
skull base surgery is a relatively new eld that is
still undergoing constant development. As with
many surgical elds, high-level evidence is missing for almost all of the burning questions with
regard to decision-making and best practice.
475
Key Learning Points
• The anterior skull base can be surgically
addressed:
– Via open approaches
– Via endoscopic approaches
– Via combined approaches
• Due to its complexity, anterior skull
base surgery (including treatment planning) should be performed in dedicated
skull base centres only.
• If the ‘dural seal’ is opened or dura is
resected during surgery, the defect must
be closed in a watertight fashion to prevent postoperative complications.
• The decision whether to choose an open,
an endoscopic or a combined approach
is dependent on many factors as well as
the individual patient. These can be con-
Tumor involves:
No
No
Ye s
Endoscopic
Fig. 36.6 Algorithm for the surgical approach to the anterior skull base. Originally published in [15]; reprint permis-
sion granted by Georg Thieme Verlag KG
Intracranial
extension
Adequate tissue for
reconstruction with
nasoseptal flap
Ye s
No
Endoscopic +
Craniotomy
• Overlying skin
• Nasal bones
• Frontal bone
• Orbital soft tissue
Extension lateral to
medial orbital wall
Ye s
No
Transfacial
Ye s
No Ye s
Intracranial
extension
Transfacial +
Craniotomy
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sidered as ‘intrinsic’ factors, such as the
location and extension of lesion, and
‘extrinsic’ factors that include the expertise of the local surgical team, having
the correct instruments and technology
available and the backup facilities to
manage potential complications.
• In clinical reality, the chosen approach—
more often than not—has to be adapted
to the individual case.
Nevertheless, both the clinical and the scientic
interest in this topic are enormous, and more controlled trials investigating those questions are
currently being performed or planned.
One of the most important questions with
regard to anterior skull base surgery that has not
been sufciently answered yet is how to decide
on an open, endoscopic or combined approach.
Apart from personal/the centre’s amount of experience with each approach as well as the equipment available, the size, location and
histopathological entity of a lesion should guide
this decision. Figure 36.6 provides an excellent
algorithm for decision-making with respect to
current knowledge.
The existing knowledge on anterior skull base
surgery by far exceeds the scope of this chapter.
For further reading (especially on decisionmaking), current consensus statements of international organizations are recommended [16,
17]. In order to improve one’s personal surgical
skills, the formation of a dedicated skull base
team as well as a participation in one or more
skull base courses is mandatory.
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