Endoscopic Transnasal Skull Base Reconstruction (ETSBR) in 420 Cases: Learning from Our Failures

Objective: ETSBR is required for cerebrospinal fluid (CSF) leak (accidental, spontaneous, iatrogenic) repair or after endoscopic removal of skull base lesions (malignant, benign and sellar lesions). The aim of this study is to analyze the different techniques of ETSBR, focusing on the evolutions of the technique, based on the analysis of failures.

Design: We retrospectively reviewed all the patients treated at our Institute from 1995 to 2011 for ETSBR.

Material and Methods: The diagnostic workup consisted of endoscopic evaluation; beta2-transferrin dosage, if possible; neuroimaging (CT, MRI); and, in selected cases, intraoperative fluorescein test. Surgery was performed through an endonasal endoscopic approach. The most employed grafts were fascia lata and mucoperiosteum harvested from the nasal cavities, combined in selected cases with vascularized pedicled flaps. Details of technique are given. The postoperative follow-up was performed with series endoscopic evaluations and CT/MRI scans.

Results: ETSBR was performed in 420 cases: in 263 CSF-leaks closures and in 157 duraplasties after SB tumors resection. Primary closure was obtained in 251/263 (95.4%) of the CSF-leak group and in 143/157 (91.1%) of the SB-tumor-resection group. In the 26/420 (6.1%) failures, revision surgery obtained secondary closure of the SB defect in 100% of cases.

Conclusion: The failures depend on the employed materials, on the reconstruction technique adopted depending on the site of defect, and on the biology of lesions. Reasons are explained with clinical cases presentation. The defect's size should not be considered a limitation. ETSBR can be considered a minimally invasive, safe, and effective procedure for ventral skull base reconstruction.