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INTRODUCTION

CLINICAL PEARLS

  • Successful endoscopic skull base surgery relies on proper preoperative workup and counseling, a collaborative relationship with neurosurgery, and meticulous surgical planning and technique for tumor resection and skull base reconstruction.

  • A detailed history and physical examination with nasal endoscopy should be performed to determine the characteristics of the lesion as well as concurrent sinonasal pathology, in addition to signs and symptoms of orbital or intracranial involvement. Preoperative imaging includes both magnetic resonance imaging (MRI) and computed tomography (CT). The decision to perform a preoperative biopsy versus primary surgical resection is dependent on the patient, the surgeon, and the suspected pathology.

  • A thorough understanding of endoscopic surgical corridors, the principles of tumor surgery, multisurgeon techniques, and skull base reconstructive options is crucial for successful endoscopic skull base surgery.

  • Perioperative management requires the multidisciplinary care of otolaryngologists, neurosurgeons, anesthesiologists, and nurses, and may include endocrinologists, ophthalmologists, and others.

  • The surgical team must be prepared to manage potentially major complications, including cerebrospinal fluid (CSF) leak, carotid artery bleed, meningitis, stroke, or death.

General Considerations

Historically, lesions of the anterior and middle cranial fossae were approached using open craniofacial techniques. With the advent and widespread adoption of high-resolution video cameras, surgical endoscopes, and image-guidance systems, the role of endoscopic approaches to the skull base has expanded in recent decades. These technological advances have resulted in improved endocrine and neurocognitive outcomes, better intraoperative visualization, reduced surgical time, less blood loss, reduced postoperative complications, less morbidity, decreased mortality, and shorter hospital stays.

With these improvements, the role of endoscopic skull base surgery (ESBS) continues to evolve. It is imperative that the endoscopic skull base surgeon has a detailed understanding of the intricate regional anatomy of the anterior, middle, and posterior cranial fossae; working knowledge of the various pathologies encountered; and precise surgical technique to preserve vital local and regional structures. Partnership with neurosurgery is critical to perform efficient, effective, and safe skull base surgery. Further, the implementation of a multidisciplinary team, including anesthesiologists, pathologists, intensivists, endocrinologists, radiologists, and both medical and radiation oncologists is paramount.

Despite these advances, ESBS presents significant challenges. This chapter describes skull base anatomy and the workup, differential diagnosis, general surgical principles, and outcomes for the endoscopic management of skull base lesions.

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