Reconstruction of skull base defects after minimally

invasive endoscopic resection of anterior skull base

neoplasms
Jern-Lin Leong, M.B.B.S.,* Martin J. Citardi, M.D.,# and Pete S. Batra, M.D.#

ABSTRACT
Background. The endoscopic resection of the cribriform plate during minimally invasive endoscopic resection (MIER) of the anterior skull
base neoplasms may result in large anterior skull base defects. The objective of this study is to describe techniques for the management of skull
base defects after MIER.
Methods: Retrospective analysis was performed on patients undergoing MIER and skull base reconstruction between April 2000 and
August 2005.
Results: Fourteen patients underwent endoscopic resection of anterior skull base tumors and reconstruction during the study period. The
mean age was 57.4 years (range, 26 – 84 years). The sex distribution was eight men and six women. The specific indications for resection
included 11 malignant and 3 benign neoplasms. Ten patients received adjuvant therapy, and in two instances this occurred before surgery.
In all instances, the dura was exposed; however, only 10 cerebrospinal fluid (CSF) leaks were encountered intraoperatively. Reconstruction
of the skull base was successfully performed, most commonly in a multilayer fashion, using an array of materials including cartilage, fat,
acellular dermal graft, and mucosal free grafts. Lumbar drain placement was used in seven cases for an average of 5.6 days. No postoperative
CSF leaks occurred. The mean follow-up was 18.0 months (range, 1–56 months).
Conclusion: This report describes methods for the reconstruction of the skull base after MIER. Reconstitution of the skull base barrier can
be achieved through application of principles for surgical repair of CSF rhinorrhea.
(Am J Rhinol 20, 476 –482, 2006; doi: 10.2500/ajr.2006.20.2931)

T raditionally, craniofacial resection (CFR) has served as the

“gold standard” for the treatment of neoplasms arising
from and/or involving the anterior skull base, nasal cavity,
center. Only patients who had undergone resection of lesions
of the anterior skull base with dural exposure were included.

and paranasal sinuses.1 Although this technique provides Surgical Technique

excellent access and exposure for successful tumor resection, All patients with anterior skull base neoplasms underwent
the approach has been associated with major complications in a detailed preoperative assessment, including diagnostic na-
30–40% of patients.2 Recently, minimally invasive endoscopic sal endoscopy, computed tomography (CT), and magnetic
resection (MIER) has been used for management of anterior resonance imaging (MRI). The decision to proceed with MIER
skull base tumors.3–5 The endoscopic resection of the skull was made by the multidisciplinary tumor board. Neurosur-
base results in large anterior skull base defects. The success of gery was involved in preoperative planning and periopera-
MIER is directly dependent on both complete oncologic re- tive management in all cases. During surgery, the neurosur-
section and skull base defect closure, which avoids the com- gical team was on standby to perform a bifrontal craniotomy
plications of persistent cerebrospinal fluid (CSF) leak, includ- if the MIER approach was unable to achieve the desired
ing meningitis, brain abscess, and death. surgical objectives or if an intracranial complication occurred.
However, open CFR was not required in this patient group.
Surgical navigation was used in all cases.
METHODS The technique for MIER has been previously described.5
Retrospective data analysis was performed on consecutive Intraoperative frozen section pathology was used to deter-
patients undergoing MIER and skull base reconstruction be- mine the extent of skull base resection. Thus, dural exposure,
tween April 2000 and August 2005 at a tertiary care medical but not formal resection, was required if the dural margin was
felt to be clear of tumor by intraoperative frozen section; in
these cases, removal of the bony skull base with a high-speed
From the *Department of Otolaryngology, Singapore General Hospital, Singapore, and
#Cleveland Clinic Foundation, Head and Neck Institute, Section of Nasal and Sinus
diamond drill was performed to achieve an oncologic margin.
Disorders, Cleveland, Ohio The skull base defect was addressed only after complete tu-
Presented at the annual meeting of the American Rhinologic Society, Los Angeles, mor resection and confirmation of clear margins by intraop-
California, September 24, 2005 erative frozen section (Fig. 1). In addition, hemostasis at the
Dr. Citardi was a member of the scientific advisory board of CBYON (Mountain View,
incised dural margins was assured through bipolar cautery
California) during 1999 –2003. He currently is a member of the scientific advisory
board of GE Medical System Navigation & Visualization (Lawrence, Massachusetts) and placement of hemostatic agents (absorbable gelatin
Address correspondence and reprint requests to Martin J. Citardi, M.D., Section of sponge, Gelfoam; Pharmacia & Upjohn, Kalamazoo, MI). The
Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, principles of reconstruction of the anterior skull base were
9500 Euclid Avenue, Desk A71, Cleveland, OH 44195 similar to techniques that have been previously described.6–8
E-mail address: [email protected]
Copyright © 2006, OceanSide Publications, Inc., U.S.A.
First, the size of the skull base defect was determined. This
required gentle direct probing along the defect edge with an

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Figure 1. This intraoperative screen capture from the surgical navigation system shows the attachment of the adenocarcinoma tumor to the
right cribriform plate. For this case, the preoperative CT and MRI scans were fused, and an image-to-patient registration was performed. The
left upper panel is the fused CT-MRI scan, and the right upper and left lower panels are the CT scans. The picture-in-picture endoscopic view
has the probe at the cribriform plate. The septum has been partially resected, and the tumor has been reflected posteriorly as it is mobilized
from its superior attachment. In this case, tumor was cleared from the bony cribriform plate and ethmoid roof, which was then resected as
a deep margin. The dura was negative for tumor by frozen section.

instrument to determine the size of the defect. If required, a (septal or split calvarium) was placed also between the two
sterile paper ruler was cut to size and used to measure the initial layers of fascia (or acellular dermal allograft). The sec-
defect directly (Fig. 2). Next, a graft of adequate size was ond layer was omitted in selected instances at the discretion of
selected to close the defect. In this series, a variety of autolo- the senior surgeon, if no intraoperative CSF leakage was
gous materials such as abdominal fat, cartilage (conchal and noted. Once these initial layers had been placed, a free mu-
septal), septal bone, temporalis fascia, and mucosal-free grafts cosal graft was draped over the reconstructed skull base (Fig.
were used. Acellular dermal allograft of medium thickness 4). These mucosal grafts were obtained from the nasal sep-
(AlloDerm; LifeCell Corp., The Woodlands, TX) was used also tum, floor, or inferior turbinate. The mucosal graft was se-
in many cases (Fig. 3). Abdominal fat graft was used to plug cured from an intranasal location as far from the primary
small dural tears or obliterate dead space on the intracranial lesion as possible to avoid inadvertent tumor seeding at the
side during the skull base reconstruction. Regardless of the tumor bed. The graft was stabilized and held in place by
chosen graft materials, a multilayered technique for recon- either fibrin glue (Tisseal, Baxter Health Care Corp.) and/or
struction was preferentially used. The initial graft consisting matrix hemostatic sealant (Floseal; Baxter Health care Corp.,
of acellular dermal allograft or fascia was fashioned to size Fremont, CA) or a microfibrillar collagen (Avitene; MedChem
and tucked along the edge of the defect on the exposed dura Products, Inc., Woburn, MA) and thrombin slurry. The nasal
with an underlay technique. Often, the graft was more diffi- cavity was then filled with a variety of materials, including a
cult to tuck along the edge of the cribriform plate defect slurry of microfibrillar collagen and topical thrombin with
because the ledge was small. The next layer usually consisted absorbable gelatin sponge (Gelfoam; Pharmacia & Upjohn) for
of acellular dermal allograft or fascia, which also was placed additional support. The entire reconstruction was supported
as an underlay graft in which its peripheral edges were by Merocel sponges (Medtronic Xomed, Jacksonville, FL)
tucked on the intracranial side of the bony defect. In selected placed in the nasal cavities.
cases, a layer of either cartilage (septal or conchal) or bone Lumbar drain management was at the discretion of the

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Figure 2. This endoscopic screen capture shows a large skull base Figure 3. Reconstruction of the defect pictured in Fig. 2 included
defect that reaches from medial orbital wall to medial orbital wall two layers of acellular dermal allograft and a free mucosal graft. The
after MIER for esthesioneuroblastoma. A disposable ruler has been acellular dermal allograft must be gently tucked between the edge of
cut and placed for measurements. This defect was ⬃2 ⫻ 3 cm. Bone the bony margin and dura as shown here.
from the ethmoid roof and cribriform plate has been removed. Mul-
tiple dural biopsy specimens were negative for neoplasm.
RESULTS
Fourteen patients underwent endoscopic resection of ante-
senior surgeon. In some instances, the neurosurgeon placed rior skull base tumors during the study period (Table 1). The
the lumbar drain at the beginning of the procedure. If an mean age was 57.4 years (range, 26–84 years). The sex distri-
active CSF leak was noted at the skull base resection, the drain bution was eight men and six women. The specific indications
was left in place. If the dura was exposed but no leak was for resection included 12 malignant and 2 benign neoplasms.
detected, the lumbar drain was removed. Alternatively, the Ten patients received adjuvant therapy and in four instances,
decision to place the lumbar drain was made intraoperatively. this occurred before surgery.
In these cases, if a difficult reconstruction was noted, a lumbar
drain was placed, but if there was no CSF leak or the leak was
small and easily controlled, a lumbar drain was omitted.
Lumbar drains were removed 4–7 days later. The lumbar
drainage rate was 8–10 cc/hour, but this was reduced if
overdrainage was suspected. Daily CSF surveillance studies,
including cell counts, protein, glucose, and cultures, were
obtained.
Patients with lumbar drains were monitored in the neuro-
surgical step-down unit or intensive care unit for 24 hours. A
postoperative head CT without contrast was obtained if in-
traoperative bleeding (viz., violation of the anterior or poste-
rior ethmoid artery or significant dural bleeding) suggested
the potential for an intracranial hemorrhage or if the skull
base defect was especially large.
All patients had their nasal packing sponges removed at
5–7 days after surgery. Meticulous sinonasal debridement
was initiated also at the first postoperative visit (within 1
week of surgery) and performed weekly/biweekly until com-
plete remucosalization of the repair site had occurred. All
patients received i.v. cefazolin (or vancomycin, if they were
allergic) while hospitalized. They were discharged with an Figure 4. A free mucosal graft, which was harvested from the nasal
oral first-generation cephalosporin (or clarithromycin, if aller- cavity floor in this case, is then placed over the acellular dermal
gic) for an additional 7–14 days. Culture-directed antibiotics allograft pictured in Fig. 3. To maintain orientation of the graft, the
were initiated for acute bacterial infections within the opera- mucosal surface has been inked with a surgical marker. The graft
tive cavity. All patients were instructed to use nasal saline was secured with Tisseal (Baxter Healthcare Corp.) and Floseal
gently after discharge. (Baxter Healthcare Corp.).

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 In all instances, the dura was exposed intraoperatively; ence/absence of CSF rhinorrhea, defect size, planned postop-
however, only 10 intraoperative CSF leaks were encountered. erative treatment (radiation therapy and chemotherapy), and
In those cases without intraoperative CSF leakage, the bony previous surgical experiences. Nonetheless, in most cases, a
skull base had been resected with an endoscopic diamond- three-layered technique was performed.
tipped drill, to clear the superior margin of the tumor and In two instances, the multilayer technique was not used. In
intraoperative frozen sections confirmed the absence of dural the first instance, only a free mucosal graft was placed over
invasion by neoplasm. The sites of skull base defect involved intact dura, because no CSF leak was present and the dura
either just the cribriform/anterior ethmoid area (10 cases) or looked remarkably healthy. In the second instance, a fat plug
spanned the entire skull base (4 cases). The size of the cribri- held in place with FloSeal was placed over a tiny pinhole leak.
form defect ranged from 2 ⫻ 4 mm (unilateral) to 35 ⫻ 40 mm This patient had undergone previous craniotomy and radia-
(bilateral). Only one CSF leak was encountered in the four tion therapy, and a multilayer closure would have required
patients whose entire cribriform plate and ethmoid roofs were significant disruption of the scarred dural boundaries. Thus,
completely resected. the standard multilayered closure was adjusted if the senior
Lumbar drains were used in seven cases for an average of surgeon concluded that a revised strategy for skull base repair
5.6 days. In patient 13, a lumbar drain was attempted, but it carried a high probability of success with low potential mor-
could not be placed because of the patient’s body habitus. All bidity.
CSF leaks were repaired successfully and no postoperative In a similar fashion, the senior surgeon chose to include
CSF leaks were noted. placement of autologous cartilage and/or bone in only four
Nasal endoscopy was performed at each office visit to patients in this series. The patients in this report were felt not
assess the state of the skull base repair and the wound healing to have elevated intracranial pressure, as opposed to a series
process in the remainder of the nasal cavity. The skull base of patients with spontaneous CSF leaks; thus, a bulky, semi-
defects generally were noted to be completely healed and rigid reconstruction was deemed unnecessary. Furthermore,
indiscernible from the remainder of the nasal cavity by 2–3 placement of free bone and cartilage grafts carried the risk of
months. Postoperative radiation therapy did not seem to ad- delayed extrusion, especially in patients for whom postoper-
versely affect remucosalization of the skull base defect. ative radiation therapy was deemed likely. Finally, lessons
Mean postoperative follow-up was 18 months (range, 1–56 from traditional CFR, where skull base reconstruction often is
months). Two patients developed acute bacterial meningitis, achieved through a pericranial flap without bone or cartilage,
which was successfully treated with i.v. antibiotics in the suggest that free bone and cartilage grafts are not required for
immediate postoperative period. Other postoperative compli- reconstruction after MIER.
cations are noted in Table 1. In this limited series, 12 patients Factors, such as grafting materials, defect size, and site and
were alive without disease and 2 patients were dead of dis- preoperative chemotherapy and/or radiation therapy, did not
ease at their last follow-up. appear to impact the success rate. Outcomes were likely more
dependent on sound technique in creating a tight closure, as
noted in previous reports.19 This observation corroborates the
DISCUSSION conclusions of other authors, who have noted that etiology,
Complete extirpation of tumors involving the anterior skull defect size, technique, and perioperative management do not
base has traditionally involved CFR.9,10 Improved survival seem to affect outcome as long as meticulous technique is
rates have been attributed to advances in this surgical tech- followed.20
nique.11 However, CFR has many disadvantages including Previous radiation or chemotherapy may be a risk factor for
increased morbidity, protracted length of both operative and failure of the reconstruction. Three patients in this series
recovery time and cosmesis issues.12 Over the past 10 years, received preoperative radiation or chemoradiation, and 10
endoscopic techniques for the resection of skull base neo- patients received it postoperatively. No failures were noted in
plasms have been introduced and have shown promising this subset of patients. Other authors have also reported no
results.3,4,5,11,13,14 association between complication rates and prior adjuvant
One of the major determinants of a successful outcome of therapy for skull base resections.1,2
any approach to skull base surgery is the ability to prevent In four cases, no intraoperative CSF leak was noted. Al-
postoperative infection and intracranial complications.15 though at least one report suggests that routine sellar recon-
Elimination of this cross-compartment contamination is par- struction is not necessary after transsphenoidal hypophysec-
amount because persistent CSF leaks can potentially lead to tomy,21 reconstruction was performed in these cases for three
serious intracranial complications including pneumocepha- reasons. First, the bloody field could have obscured an occult
lus, meningitis, brain abscess, and seizures.6,16 Importantly, CSF leak. Second, concern that the planned postoperative
endoscopic techniques have emerged as the preferred surgical adjuvant treatment (chemotherapy and/or radiation therapy)
modality for the management of CSF leaks with a wide range could lead to delayed CSF leak suggested that preemptive
of etiologies.6,17,18 These experiences serve as the foundation reconstruction, a procedure with low morbidity, was war-
for endoscopic reconstruction of the skull base after MIER. ranted. Most importantly, the morbidity of reconstruction is
In this series, all patients except for two underwent repair minimal; however, the potential morbidity of failure to recon-
of the skull base defect using the standard multilayered tech- struct (delayed CSF leak, meningitis, and pneumocephalus) is
nique with a variety of graft materials. The specific techniques quite large. Thus, there was considerable bias in favor of
(i.e., selected materials, number of layers, etc.) used for skull reconstruction in this series.
base reconstruction was at the discretion of the senior sur- Neurosurgical expertise was available in all of these
geon. Factors in this decision-making process included pres- cases; their involvement was twofold. First, the neurosur-

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Table 1 Clinical data
ID Pathology Preop Preop Curative Margins Defect Size
XRT CTx Intent (mm)
1 Squamous cell carcinoma, inverted papilloma N N Y ⫺ 20 ⫻ 20
2 Leiomyosarcoma N N N ⫹ 5⫻ 5
3 Sinonasal undifferentiated carcinoma N Y Y ⫺ 4 ⫻ 13

4 Mucosal melanoma N N Y ⫺ 35 ⫻ 40
5 Inverted papilloma N N Y ⫺ 4⫻ 6

6 Sinonasal undifferentiated carcinoma Y Y Y ⫺ 5 ⫻ 15

7 Esthesioneuro-blastoma N N Y ⫺ 10 ⫻ 15

8 Low-grade angiomyxoid neoplasm N N Y ⫺ 4⫻ 4

9 Squamous cell carcinoma, inverted N N Y ⫺ 2⫻ 4

papilloma
10 Esthesioneuro-blastoma N N Y ⫺ 10 ⫻ 35

11 Mucosal melanoma N N N ⫺ 3 ⫻ 10

12 Adenocarcinoma N N Y ⫺ 6 ⫻ 16

13 Esthesioneuro-blastoma Y Y Y ⫺ 20 ⫻ 35
14 Nasal meningioma Y N N ⫹ 20 ⫻ 20

*Graft materials are listed from superior to inferior. All mucosal grafts were free mucosal grafts.
#Proton beam radiation therapy.
§Lumbar drain was attempted, but it could not be placed because of the patient’s body habitus.
CTx ⫽ chemotherapy; DVT ⫽ deep venous thrombosis; intraop ⫽ intraoperative; N ⫽ no; preop ⫽ preoperative;
postop ⫽ postoperative; XRT ⫽ radiation therapy; Y ⫽ yes.

geons assisted with lumbar drain management. Second, also may facilitate the healing process. On the other hand, the
they were available for possible bifrontal craniotomy if the other senior surgeon (M.J.C.) reserves lumbar drainage for
MIER approach was unable to achieve complete tumor those cases where elevated intracranial pressure is suspected,
extirpation at the skull base or if an intracranial com- where the reconstruction was especially challenging, or where
plication occurred. No patient required craniotomy in this a CSF leak is suspected in the immediate postoperative pe-
series. riod. Intraoperative leakage through the defect provides a
Usage of lumbar drains for repair of CSF leaks is contro- means for decompression of the CSF leak space, and the
versial. Serious complications have been reported with lum- resultant equalization between the intracranial and extracra-
bar drain placement, including prolonged spinal tap head- nial spaces facilitates graft placement. Furthermore, the nor-
aches, meningitis, and even cerebral herniation resulting in malization of CSF pressures after graft placement helps secure
death.22,23 For anterior skull base defect repair, some have the graft (which is tucked on the intracranial side of the
used the drain intraoperatively and removed it on completion defect), because the CSF pressure holds the graft between the
of the repair,2 while others have avoided use of the drain dura and bone defect rim.
altogether.24 The senior surgeons in this report used divergent
strategies for this specific issue. One surgeon (P.S.B.) routinely CONCLUSIONS
used lumbar drainage, which may be placed before the tumor Endoscopic techniques are increasingly used for resec-
resection. In this view, lumbar drainage is especially impor- tion of anterior skull base neoplasms. The success of this
tant for repair of large skull base defects, because intraoper- strategy depends on complete tumor extirpation and repair
ative CSF lumbar drainage decompresses the intracranial of the skull base defects. This study confirms that the
compartment and may facilitate placement and optimal posi- endoscopic techniques for CSF leak repair can be safely
tioning of the grafts. In the immediate postoperative period, extended to large skull base defects created during mini-
reducing the intracranial pressure directly on the graft bed mally invasive anterior skull base tumor resection. Metic-

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Table 1 Continued
Reconstruction Layers* Intraop LP Postop Postop Postop F/U
CSF Leak (days) XRT CTx Complications (mon)
Cartilage, fascia, mucosa Y Y (4) Y Y N 56
Fat, cartilage, mucosa Y Y (6) Y# N Epistaxis 50
Acellular dermal allograft, mucosa N N (0) Y Y Left abducens 32
nerve palsy
(transient)
Cartilage, mucosa Y Y (5) Y Y N 32
Fat, cartilage, mucosa Y N (0) Y# N Bacterial 17
meningitis
Mucosa N Y (6) Y N DVT 15
Acellular dermal allograft, cartilage, Y Y (6) N N N 14
acellular dermal allograft, mucosa
Acellular dermal allograft, acellular dermal Y Y (7) N N Pneumonia 14
allograft, mucosa
Acellular dermal allograft, acellular dermal Y Y (5) N N N 5
allograft, mucosa
Acellular dermal allograft, cartilage, N N (0) Y N N 5
acellular dermal allograft, mucosa
Acellular dermal allograft, acellular dermal Y N (0) Y Y DVT 4
allograft, mucosa
Acellular dermal allograft, acellular dermal Y N (0) Y Y N 4
allograft, mucosa
Acellular dermal allograft, mucosa N N (0) Y Y N 4
Fat Y N (0)§ N N Bacterial 1
meningitis

ulous technique, regardless of the grafting materials, size, ing acellular dermal allograft. Laryngoscope 113:496–501,
and site of the defect, appears to be the key factor in 2003.
achieving a successful reconstruction. 9. Van Tuyl R, and Gussack GS. Prognostic factors in cranio-
facial surgery. Laryngoscope 101:240–244, 1991.
10. Janecka IP. Anterior and anterolateral craniofacial resection.
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