C o m b i n e d En d o s c o p i c an d

O p e n A p p ro a c h e s i n t h e
M a n a g e m e n t o f S i n o n a s a l an d
Ven t r a l Sk u l l B a s e M a l i g n a n c i e s
James K. Liu, MDa,b,*, Anni Wong, MS
c,d
,
Jean Anderson Eloy, MDe,f,g,h

KEYWORDS
 Skull base malignancy  Skull base defect  Skull base surgery
 Sinonasal malignancy  Endoscopic endonasal surgery  Craniotomy  Transbasal
 Nasoseptal flap

KEY POINTS
 The use of combined transcranial and endoscopic endonasal approaches or so-called
cranionasal approaches to the anterior ventral skull base and paranasal sinuses remain
an important option in the surgical treatment of sinonasal and ventral skull base
malignancies.
 The modified 1-piece extended transbasal approach provides wide panoramic exposure
to tumor that invades the frontal lobes, orbital roofs, and cribriform plate without using a
transfacial incision or orbital bar removal.
Continued

Financial Disclosures: None.

Conflicts of Interest: None.
a
Department of Neurological Surgery, Center for Skull Base and Pituitary Surgery, Neurolog-
ical Institute of New Jersey, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100,
Newark, NJ 07103, USA; b Department of Otolaryngology – Head and Neck Surgery, Rutgers
New Jersey Medical School, Newark, NJ, USA; c Department of Neurological Surgery, Neurolog-
ical Institute of New Jersey, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100,
Newark, NJ 07103, USA; d Department of Otolaryngology – Head and Neck Surgery, Neurolog-
ical Institute of New Jersey, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100,
Newark, NJ 07103, USA; e Department of Neurological Surgery, Rutgers New Jersey Medical
School, Newark, NJ, USA; f Rhinology and Sinus Surgery, Otolaryngology Research, Endoscopic
Skull Base Surgery Program, Department of Otolaryngology – Head and Neck Surgery, Neuro-
logical Institute of New Jersey, Rutgers New Jersey Medical School, 90 Bergen Street, Suite
8100, Newark, NJ 07103, USA; g Center for Skull Base and Pituitary Surgery, Neurological Insti-
tute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ, USA; h Department of
Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA
* Corresponding author: Department of Neurological Surgery, Center for Skull Base and Pitu-
itary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, 90 Ber-
gen Street, Suite 8100, Newark, NJ 07103.
E-mail address: liuj10@njms.rutgers.edu

Otolaryngol Clin N Am 50 (2017) 331–346

http://dx.doi.org/10.1016/j.otc.2016.12.009 oto.theclinics.com
0030-6665/17/ª 2017 Elsevier Inc. All rights reserved.
332 Liu et al

Continued
 The endoscopic endonasal approach can be combined with the transbasal approach for
secondary inspection from below after tumor removal from the transcranial exposure,
further resection of tumor within the sinonasal cavity, and reconstruction with a vascular-
ized pedicled nasoseptal flap, if needed.
 Skull base reconstruction can be performed using a simultaneous pericranial flap from
above and a nasoseptal flap from below (double flap), especially when postoperative
adjuvant radiation therapy is anticipated.

Abbreviations
CTA Computed tomography angiography
EEA Endoscopic endonasal approach
CSF Cerebrospinal fluid

INTRODUCTION

Since the conception of the bifrontal craniotomy by Frazier in 1913,1 Derome2 and
Tessier and colleagues3 popularized the transbasal approach to the anterior ventral
skull base. Numerous modifications of the transbasal approach have been developed,
each adding varying degrees of bone removal of the supraorbital bar, orbital roof and
wall, lateral orbital rims, nasal bones, and paranasal sinuses (frontal, ethmoid, and
sphenoid sinuses). In 1988, Raveh and Vuillemin,4,5 described the subcranial
approach for the removal of fronto-orbital and anteroposterior skull base tumors,
which entailed nasal and orbital osteotomies and minimal frontal lobe retraction. In
1991, Kawakami and colleagues,6 presented the extensive transbasal approach, per-
forming en bloc bilateral orbital roof and frontal sinus osteotomy. This allowed for ac-
cess to tumors extending laterally into the anterior cranial fossa. Sekhar and
colleagues7 discussed the extended frontal approach in 1992, which added an orbito-
frontal or orbitofrontoethmoidal osteotomy. These transbasal modifications have
allowed for increased posterior and inferior surgical view toward the clivus with less
frontal lobe retraction. These midline subfrontal approaches to the anterior ventral
skull base and paranasal sinuses remain critical in the treatment of anterior ventral
skull base and sinonasal malignancies.
In the past decade the role of the pure endoscopic endonasal approach (EEA) has
gained increasing popularity, driven by continuous advances in endoscopic instru-
mentation, intraoperative image guidance, and surgical technique. Resections with
negative margins via a purely EEA have been successfully performed for tumors
confined to the nasal cavity and paranasal sinuses with radiologic evidence of normal
cribriform plate and upper ethmoid sinuses.8
However, limitations of the pure EEA arise when there is significant intracranial
extension or considerable extension beyond the lamina papyracea.8,9 For instance,
when en bloc resection of the tumor including the cribriform plate is necessary, it
may be best accomplished with an anterior craniotomy.8,10 Thus, open approaches
remain an integral component in our surgical armamentarium. In the bifrontal trans-
basal approach, one can access the cribriform plate and perform a total ethmoidec-
tomy, sphenoidotomy, and midline clivectomy down to the craniovertebral junction.
Traditionally, the transbasal approach was often combined with a transfacial approach
(combined craniofacial approaches) to treat a vast majority of sinonasal skull base ma-
lignancies. This combined approach allowed for access to tumors residing beneath
the orbit in the superolateral aspect of the maxillary sinus, where the bifrontal
 Management of Ventral Skull Base Malignancies 333

approach alone was restricted from.11 Although the transfacial approach provides
ample exposure for complete tumor removal, it often involved rather invasive tech-
niques, including extensive facial incisions, facial disassembly, lateral rhinotomy, mid-
facial degloving, and/or facial osteotomies, leaving displeasing cosmetic results.11,12
Infectious complications or inadequate healing may lead to malunion of bones or loss
of grafts, resulting in unsightly scars and disfigurement.12 Additionally, compared with
craniofacial resection, transnasal endoscopic resection of anterior ventral skull base
tumors has been demonstrated to be associated with decreased hospital and inten-
sive care unit (ICU) stay, decreased estimated blood loss, and faster recovery.13–15
Subsequently, the EEA has become a more favorable adjunct (endoscopic-assisted
craniofacial approaches or cranionasal approaches) due to its superior panoramic
visualization, illumination, and avoidance of transfacial skin incisions.11 In this article,
we discuss the role of combined transcranial and EEA approaches (combined cranio-
nasal approach) in the surgical management of ventral skull base malignancies
(Figs. 1–3).

COMBINED TRANSBASAL AND ENDOSCOPIC ENDONASAL APPROACH

With the advent of skull base endoscopy, the EEA and its extended variations have
changed the paradigm by which ventral skull base lesions are treated. In recent years,
the surgical landscape of endoscopic skull base surgery has evolved as this anatomic
territory became better understood. By taking advantage of the natural anatomic cor-
ridors, such as the transnasal, transsphenoidal, transethmoidal, and transmaxillary
corridors, structures from the clivus to the Meckel cave to the pterygopalatine fossa

Fig. 1. (A–C) Preoperative MRI of esthesioneuroblastoma in sinonasal cavity with extension

through anterior skull base and significant intracranial invasion. A combined cranionasal
approach was performed to achieve complete resection. Reconstruction of the skull base
defect was performed using the double-flap technique. (D–F) Postoperative MRI at 4 years
shows no evidence of tumor recurrence.
334 Liu et al

Fig. 2. (A–C) Preoperative MRI of sinonasal teratocarcinosarcoma with intracranial exten-

sion through the anterior skull base and significant brain invasion. A combined cranionasal
approach was performed to achieve complete resection. Reconstruction of the skull base
defect was performed using the double-flap technique. (D–F) Immediate postoperative
MRI shows no evidence of residual tumor.

Fig. 3. (A–C) Preoperative MRI of sinonasal undifferentiated carcinoma with significant

brain invasion and lateral extension. A combined cranionasal approach was performed to
achieve near total resection. Reconstruction of the skull base defect was performed using
the double-flap technique. (D–F) Immediate postoperative MRI shows tumor adherent to
the orbital apex bilaterally.
 Management of Ventral Skull Base Malignancies 335

are now accessible without external incisions.11,16–18 The versatility of EEA has
increased minimally invasive surgical access to the ventral skull base dramatically.
In our practice, most sinonasal and anterior ventral skull base malignancies are treated
with a purely endoscopic endonasal transcribriform approach. However, if one is to
choose a transbasal approach from above, this can be used in conjunction with a
complementary EEA from below to treat large lesions involving multiple anatomic
compartments (see Figs. 1–3). The transbasal approach provides exposure from
the third ventricle to the base of the clivus with relatively limited frontal lobe retrac-
tion.19 In the past, such lesions were traditionally treated with extended transbasal ap-
proaches combined with open transfacial approaches involving facial skin incisions
and facial osteotomies. Because the extended EEAs provide wide panoramic access
and visualization to the ventral skull base in the sagittal and coronal planes, the tradi-
tional transfacial approaches have gradually fallen out of favor and use. From a trans-
cranial approach, the anterior nasal cavity and superolateral regions of the maxillary
sinus are difficult to visualize (blind spots). However, the EEA allows excellent visual-
ization and access to the entire paranasal sinuses, including these blind spots, partic-
ularly with angled endoscopy. Through this synergistic combined approach, the
surgeon can work from above to control and remove intracranial tumor, and also
from “below” to control tumor in the sinonasal cavity. A combined approach also
can be used from a reconstruction strategy because the EEA can provide an additional
vascularized pedicled nasoseptal flap, if needed. This may be useful in cases in which
the pericranial flap is compromised from prior craniotomies, or needs to be supple-
mented from below. Alternatively, the pericranial flap can serve as the primary source
of vascularized reconstruction if the nasoseptal flap is compromised or invaded by a
sinonasal malignancy.

SURGICAL CONSIDERATIONS: APPROACH SELECTION

Several considerations go into deciding on an appropriate operative approach for

sinonasal skull base malignancies, such as anatomic location, degree of tumor exten-
sion in the sagittal and coronal plane, degree of intracranial involvement, vascular or
cranial nerve encasement, brainstem compression, tumor consistency, history of prior
surgical approach, surgeon’s preference, and level of experience. When selecting the
optimal approach based on anatomic location, consideration should be taken to
choose an approach that not only has the most direct route to the tumor, but also op-
timizes exposure and visualization of the tumor interface with critical structures so as
to avoid neurologic damage and surrounding vital structures, such as the orbit, optic
nerves, carotid arteries, cavernous sinus, and frontal lobes.
History of prior surgery is important and may affect the surgical approach selected.
Postoperative changes, such as altered anatomy, loss of landmarks, edema, and
fibrosis may make definitive surgical resection and accurate evaluation of the extent
of disease more challenging.20 Individual surgeons may have different thresholds as
to when an open approach should be warranted or added to their endoscopic resec-
tion. Hanna and colleagues20 held a low threshold for adding a craniotomy to the EEA
(combined cranionasal approach) if there was dural involvement or transdural spread
and/or invasion of the skull base, whereas Nicolai and colleagues21 continued EEA for
selected patients with skull base invasion and focal dural infiltration. The surgeon must
also be aware that some cases with significant tumor extension into multiple compart-
ments may require a combination of more than 1 approach to adequately remove the
tumor. Typically, the use of EEA exclusively is contraindicated when there is involve-
ment of skin and subcutaneous tissue, nasolacrimal sac, anterior table of frontal sinus,
336 Liu et al

carotid artery, and extensive dural and brain parenchymal involvement. In these in-
stances, the addition of a transfacial or transcranial approach is warranted for optimal
resection of the malignancy.18,21 Thus, it is important to maintain the open approaches
in the surgical repertoire for various indications.

PREOPERATIVE CONSIDERATIONS

Preoperative MRI is essential to assess the tumor and to check for intracranial exten-
sion. Computed tomography angiography (CTA) is useful to assess the anatomy of the
anterior and posterior arterial circulation relative to the tumor, to rule out any vascular
encasement, and to study the neighboring venous anatomy, including the cavernous
sinus, petrosal sinuses, and any large draining veins. CTA is preferred over magnetic
resonance angiography, as it also shows the bony anatomy of the skull base in high
resolution. Digital subtraction angiography is reserved for complicated vascular anat-
omy not adequately assessed on CTA or for balloon test occlusion in cases of signif-
icant arterial encasement. In patients with sellar and suprasellar tumor involvement,
baseline pituitary function should be assessed with appropriate endocrine testing. It
is important to obtain formal baseline neuro-ophthalmological testing for patients
who present with visual disturbances due to optic nerve and/or orbital involvement.

SURGICAL TECHNIQUE
Patient Positioning
After general endotracheal anesthesia and appropriate arterial and venous access is
obtained, the patient is positioned supine and the head placed in 3-pin fixation
(Fig. 4). The bed is flexed 10 to 15 to facilitate venous drainage. The neck is slightly
extended to promote frontal lobe relaxation away from the anterior ventral skull base
and to reduce the need for brain retraction.
Neuronavigation can be useful and can be used to plan the craniotomy and verify
anatomic landmarks. Neurophysiologic monitoring of somatosensory and motor
evoked potentials are performed. Additional neurophysiologic monitoring modalities
can be used as needed depending on the location of the tumor. Antibiotics, mannitol,
decadron, and antiepileptics are administered before skin incision.
Skin Incision
A preauricular bicoronal skin incision is planned behind the patient’s hairline that ex-
tends from one zygoma to the other, no more than 1 cm anterior to the tragus
(see Fig. 4). The nose and nares are also prepped, in case endoscopic endonasal

Fig. 4. (A, B) For a combined cranionasal approach, the patient is positioned supine with the
head in 3-pin fixation. A standard bicoronal incision is used.
 Management of Ventral Skull Base Malignancies 337

exploration is required to remove additional tumor from the sinuses or to harvest a

vascularized pedicled nasoseptal flap to aid in anterior ventral skull base reconstruc-
tion. The face can be prepped in case an additional open transfacial is required.
Abdominal and thigh incisions also can be prepared for fat and fascia lata graft har-
vesting, if needed.
A bicoronal skin incision is made and the scalp is elevated in a 2-layer fashion. A
galeocutaneous flap is elevated anteriorly, leaving the pericranium and temporalis fas-
cia and muscle attached to the skull. Interfascial dissection of the temporalis fascia is
performed so that the superficial fat pad is elevated with the scalp to protect the fron-
totemporal branch of the facial nerve. When dissecting around the orbital rims, care is
taken to preserve the supraorbital and supratrochlear neurovascular bundles, which
provide the blood supply to the pericranium. The galeocutaneous flap is undermined
posteriorly to the incision by several centimeters to allow for a longer pericranial flap
harvest. The pericranium is then incised posteriorly behind the skin incision and later-
ally just above the superior temporal line, and elevated as a separate vascularized flap
that is pedicled anteriorly (Fig. 5A, B).
Subperiosteal elevation of the scalp and pericranial flap exposes the orbital rims
anteriorly, with care to preserve the supraorbital nerve at the supraorbital notch. In
cases in which the supraorbital notch is closed by a fibrous ring, the nerve can be dis-
placed inferiorly away from the orbital roof subperiosteally. However, in cases in which
the supraorbital nerve exits from a closed osseous ring, an osteotome may be used to
release the nerve from the orbital rim. The frontonasal suture is also exposed in the
midline to obtain a low-lying bifrontal osteotomy at the nasion. The lateral orbital
rims also can be exposed subperiosteally down to the frontozygomatic suture after
performing interfascial dissection of the temporalis fascia. The superior aspect of tem-
poralis muscle and fascia is reflected inferiorly to expose the frontal keyhole just below
the superior temporal line, behind the orbital rim.

Fig. 5. Intraoperative photographs of the modified 1-piece extended transbasal approach.

(A, B) Harvest of vascularized pedicled pericranial flap. (C–E) Bifrontal craniotomy incorpo-
rates the anterior wall of the frontal sinus down to the nasion and along the roofs of the
orbit. This allows the lowest basal trajectory to the skull base without having to remove
the supraorbital bar. (F) The superior sagittal sinus is ligated at the level of the crista galli
and the falx cerebri is incised to the free edge.
338 Liu et al

Modified 1-Piece Extended Transbasal Approach

The standard transbasal approach is simply a bifrontal craniotomy without removal of
the supraorbital bar. Access to the cribriform region and paranasal sinuses can be
limited without significant frontal lobe retraction due to obstruction of line of sight
by the overhang of the supraorbital bar. On the other hand, the extended transbasal
approach, which typically involves a standard bifrontal craniotomy followed by a su-
praorbital bar osteotomy that is performed in a 2-piece fashion, provides a low basal
trajectory into the anterior skull base without significant brain retraction.19 Cosmetic
reconstruction of the frontal bone and supraorbital bar in the traditional 2-piece
approach can be a bit more cumbersome, as small gaps between the bone flaps
can be apparent and titanium plates used in the forehead area can be more sensitive
in some patients. We previously described a modified 1-piece extended transbasal
approach that incorporates the bifrontal bone flap with the anterior table of the frontal
sinus without requiring removal of the supraorbital bar (see Fig. 5C–E).22,23 A low-lying
osteotomy is made through the outer table of the frontal sinus that follows the contour
of the floor of the anterior cranial fossa to provide a low basal exposure to the anterior
fossa without any obstruction of line of sight.
A burr hole is made directly over the superior sagittal sinus superiorly with exposure
of dura on each side of the sinus. Another set of bur holes is made in the keyhole region
behind the orbital rim and below the superior temporal line to expose the frontal lobe
dura. A craniotome is used to connect the midline burr hole to both frontal keyholes.
The craniotome is then used to make a cut from the frontal burr hole across the lateral
aspect of the supraorbital rim in a lateral-to-medial fashion. Inferiorly, an osteotomy is
made through the outer table of the frontal sinus at the nasofrontal suture using a C-1
drill bit (Medtronic, Minneapolis, MN). The osteotomy is carried laterally on both sides,
and follows the contour of the anterior cranial fossa and orbital rims. The intersinus
septum of the frontal sinus anchors the bifrontal bone flap to the skull base and needs
to be disconnected to allow elevation of the flap. This osteotomy is made by using an
osteotome at the nasofrontal suture, and tapping it with a mallet. It is important to visu-
alize incremental advancement of the osteotome while tapping with gentle force. The
bone over the supraorbital rim tends to be thick as well, and may need an osteotome
to release the bone flap. Once the bone flap is loose and mobile, a curved dissector is
used lift the bone flap from the frontal dura and a periosteal elevator is used to fracture
the posterior table of the frontal sinus to release the bone flap.
This technique provides a low basal exposure of the cribriform plate and orbital
rims. In essence, it provides the same midline exposure as an extended transbasal
approach without having to remove the supraorbital bar and thus avoids dissection
of the periorbita and minimizes orbital trauma. The 1-piece method facilitates fast
and easy cosmetic reconstruction and avoids titanium plates in the supraorbital re-
gion. Although others have described variations of a 1-piece transbasal approach
with removal with the supraorbital bar,24 our technique eliminates the need for supra-
orbital removal by taking advantage of the frontal sinus anatomy. After removal of the
bone flap, the frontal sinus is exenterated and cranialized by removing the sinus mu-
cosa and the posterior table of the frontal sinus. The nasofrontal ducts are packed with
betadine-soaked Gelfoam before opening the dura.
To expose the intradural component of the tumor, the dura is opened transversely
along the frontal base and the superior sagittal sinus is ligated as anteriorly
as possible, near the crista galli (see Fig. 5F). The sinus is then divided sharply and the
incision is carried along the falx cerebri toward the free edge.25 With bilateral frontal lobes
exposed, dissection can be carried out using either a subfrontal or interhemispheric
 Management of Ventral Skull Base Malignancies 339

corridor. Care is taken to avoid compromise of any bridging veins so as to avoid a venous
infarct. The intradural portion of the tumor is removed with care to create a plane to sepa-
rate the frontal lobes from the tumor capsule (Fig. 6A–C). Solid and firm tumors can be
debulked with an ultrasonic aspirator, whereas hemorrhagic and friable tumor may need
to be removed in a piecemeal fashion suctions and bipolar cautery. After tumor removal,
the frontal lobes are inspected and frozen sections are sent for margins.
Before entering the sinonasal cavity via the cribriform plate, the dura can be closed
in a watertight fashion with a dural patch graft (Fig. 6D). The remainder of the extra-
dural tumor can be removed and access to the clivus can be achieved through the
transcribriform corridor microsurgically (Fig. 6E, F). The cribriform plate and crista galli
are drilled off to expose the anterior and posterior ethmoid sinuses and lamina papy-
racea. The anterior and posterior ethmoidal arteries and coagulated and divided
sharply. Care is taken to avoid retraction of an incompletely coagulated ethmoidal ar-
tery back into the globe to avoid an orbital hematoma. Removal of the planum sphe-
noidale posteriorly provides exposure of the sphenoid sinus. Both optic canals are
identified posterolaterally within the sphenoid sinus. Bilateral bony prominences
formed by the cavernous segment of the internal carotid arteries are identified on
either side of the sella. The sphenoid sinus can be widened, and the sellar floor can
be removed if access to the clivus is needed. Exposure of both maxillary sinuses
can also be achieved. However, visualization to the anterior nasal cavity and supero-
lateral aspect of the maxillary sinus is limited from above (blind spots).11 Thus, further
inspection for remaining tumor from below via an EEA is performed. Endoscopic
debulking of the intranasal portion of the lesion also can be performed if necessary.21
It is important to preserve the nasal septum and mucosa during the tumor removal, in
case a nasoseptal flap is needed for reconstruction (see later in this article).

Reconstruction
The large skull base defects and communication with the nasal sinuses present a
unique challenge in reconstruction. Although endonasal repair of smaller skull base

Fig. 6. Intraoperative photographs of patient in Fig. 2. (A, B) Intracranial tumor (T) is

removed and dissected away from the right frontal lobe (RF) and left frontal lobe (LF).
(C) The cribriform plate (CP) is exposed after removal of the intracranial portion of the tu-
mor. (D) The intracranial cavity is closed in a watertight fashion by suturing a dural graft
(DG) to secure the brain contents from the sinonasal cavity. (E, F) The CP is entered and
the tumor is removed from the sinonasal cavity through the transcranial approach. IT, infe-
rior turbinate; NS, nasal septum; OR, orbital roof; SS, sphenoid sinus.
340 Liu et al

defects with fascial or mucosal grafts in conjunction with tissue sealants have been
successful in preventing cerebrospinal fluid (CSF) leaks, its adequacy for endonasal
reconstruction of major skull base and dural defects is of debate.13,20,26 Vascularized
tissue is optimal for reconstruction with goals of separation of the intracranial
compartment from the sinonasal cavity and prevention of postoperative CSF leakage.
Additionally, vascularized flaps promote rapid and complete healing.26–28 Pericranium
is a commonly used vascularized tissue flap that is readily available with a bicoronal
incision. Undermining beneath the incision posteriorly provides several additional cen-
timeters of pericranium for increased surface area of coverage. It is important to
attempt watertight closure of durotomies and dural defects, if possible, before place-
ment of the pericranial flap. We typically suture a dural patch using acellular dermal
allograft at the cribriform dural defect of the anterior ventral skull base. Endoscopic
endonasal inspection of the skull base reconstruction from below can be very useful
in ensuring an adequate pericranial flap reconstruction to prevent CSF leakage. This
strategy can allow an endoscopic-assisted repair with direct visualization of the ante-
rior ventral skull base repair and optimal positioning of the pericranial flap.
If postoperative radiation therapy is anticipated, particularly for sinonasal skull base
malignancies, one can consider using a “double-flap” technique in which a pericranial
flap is simultaneously used with a nasoseptal flap (Figs. 7 and 8).29 The 2 flaps can
complement each other at their respective areas of weakness. The pericranial flap
is strongest anteriorly at the region of the frontal sinus and cribriform plate, whereas
the nasoseptal flap is strongest at the area of the clivus defect. When used together,
these 2 vascularized tissue flaps can provide optimal skull base reconstruction in
select cases that are at high risk of postoperative CSF leakage.
In some instances, a vascularized pedicled nasoseptal flap may be used as a
salvage strategy if the pericranial flap is unavailable due to prior usage in revision cra-
niotomies.27 This durable yet pliable flap is robustly vascularized by the posterior
nasoseptal arteries arising from the sphenopalatine artery. Its large surface area
and superior rotational arc allow for flexibility in flap design, contributing to its high

Fig. 7. Illustration demonstrating the double-flap reconstruction technique used in com-

bined cranionasal approach. Simultaneous pericranial flap from above and nasoseptal
flap from below are used for reconstruction of the extensive anterior skull base defect.
(Courtesy of Chris Gralaap, MA, CMI, Fairfax, CA.)
 Management of Ventral Skull Base Malignancies 341

Fig. 8. Intraoperative photographs of a simultaneous double-flap reconstruction after com-

bined cranionasal removal of an anterior skull base malignancy. (A) Anterior skull base (ASB)
defect is visualized anterior and inferior to the frontal lobes (FL) and between the orbits
(Ob). (B) The vascularized pericranial flap (PCF) is rotated over the ASB defect. The distal
redundant portion is used to cover the frontal lobe dural closure. Here, an additional acel-
lular dermal allograft (ADA) was placed as an onlay graft over the dural closure. (C) Endo-
nasal endoscopic view of the PCF. (D, E) A vascularized pedicled nasoseptal flap (NSF) is
rotated over the PCF to provide double-flap reconstruction. The vascular pedicle (VP) is
preserved.

rate of success in ventral skull base reconstruction.26,27 It is paramount to inspect the

nasal septal mucosa to ensure that it is free of tumor invasion before considering it for
reconstruction. The surface area and dimensions of the nasoseptal flap available for
use is limited by tumor involvement of the nasal septum. In cases of tumor involvement
of the superior nasal septum, tissue from the nasal floor mucosa, lateral wall of the
nasal cavity, and lower septum can be harvested to create an extended nasoseptal
flap.18,30 However, if there is significant bilateral septal involvement, the nasoseptal
flap may not be a viable option, and thus one has to rely solely on pericranial flap
reconstruction. In cases of revision surgery in which the pericranial and nasoseptal
flap are both unavailable, other vascularized reconstructive alternatives, such as the
temporoparietal fascial, galeopericranial, and palatal flaps can be considered.18,26
Free tissue transfer with microvascular anastomosis (free flap) is another feasible
option.26,31
The flap reconstruction is bolstered with Surgicel, followed by gentamicin-soaked
Gelfoam pledgets, and finally buttressed with several inflatable Merocel (Medtronic
Xomed, Jacksonville, FL) nasal tampons. The packing is left in the nasal cavity for
approximately 10 to 12 days to promote adherence of the flap to the ventral skull
base. The patient is maintained on oral antibiotics until the nasal packing is removed
endoscopically as an outpatient. The bone flap is replaced and fixed with titanium
plates. Care is taken not to compress or strangulate the pericranial flap to avoid
342 Liu et al

ischemic compromise to the reconstruction. Meticulous multilayered wound closure is

then performed. We generally avoid lumbar drains for transcribriform defects32 so as
to avoid complications of intracranial hypotension, tension pneumocephalus, and
thromboembolic complications associated with prolonged bedrest.

POSTOPERATIVE MANAGEMENT

Postoperatively, the patient is monitored in the neurosurgical ICU. Hourly neurologic

examinations in the ICU should be performed for the first 24 to 48 hours, including
assessment for CSF leakage. Hemodynamic monitoring with an arterial line is used
with intravenous infusion of an antihypertensive or hypertensive (pressor) agents to
maintain normal blood pressures. Routine blood work is performed including com-
plete blood count, coagulation profile, electrolytes, and arterial blood gas. Strict intake
and output is monitored, especially if there is concern for diabetes insipidus in cases of
parasellar involvement. We typically administer broad-spectrum intravenous antibi-
otics postoperatively that cover sinonasal flora with blood-brain-barrier penetration
for 72 hours after surgery. This is transitioned to oral antibiotics that are continued
for the duration of nasal packing.
Both intracranial hypertension and hypotension can be concerns in the immediate
postoperative period and the clinical presentations can be similar. Any change of
neurologic examination should warrant an immediate computed tomography scan
to rule out a mass lesion such as a hematoma or tension pneumocephalus, or signs
of intracranial hypotension.33 Prophylactic lumbar drainage should be used judi-
ciously, as it can precipitate intracranial hypotension and tension pneumocephalus.
In our practice, we typically do not use postoperative lumbar drainage for cranionasal
approaches so as to avoid these risks.32
CSF leakage can present in the immediate postoperative period or in a delayed
fashion. Although very low-flow CSF leaks can sometimes be successfully treated
with lumbar drainage, most significant CSF leaks require surgical exploration to
directly repair the site of the fistula. A revision craniotomy can be avoided by using
an EEA to inspect the site of the fistula, reinforce any persistent defects with tissue
grafts (fat, fascia lata, acellular dermal allografts), reposition the pericranial flap,
and/or augment the repair with a vascularized nasoseptal flap.

DISCUSSION

Traditionally, extensive malignant tumors of the paranasal sinuses and ventral skull
base have been surgically managed via a transcranial-transfacial (combined craniofa-
cial) approach and postoperative radiotherapy with satisfactory success. However,
craniofacial resection is associated with significant perioperative morbidity, mortality,
and complications.8,13,34 These limitations prompted the search for safer and
improved methods for the surgical management of extensive paranasal sinus and
anterior ventral skull base malignancies, which would improve the patient’s function-
ality and quality of life with satisfactory cosmetic results while preserving oncological
principles. Advancing developments in endoscopic surgical technology, refinements
in endoscopic techniques, and increased familiarity of the endoscopic endonasal
anatomy have allowed the EEA to transcend its expected uses, where its applicability
has expanded from its initial use for the treatment of inflammatory paranasal sinus dis-
ease to resection of benign sinonasal neoplasms,9,35,36 and ultimately to resection of
malignant neoplasms, including those of the ventral skull base.21,37,38 In tumors with
significant intracranial extension that is not amenable to a pure EEA, a combined
transcranial/EEA (combined cranionasal approach) can be performed.8,10,12,37,39
 Management of Ventral Skull Base Malignancies 343

In 1997, Yuen and colleagues39 first described the combined transcranial and endo-
scopic transnasal approach for the resection of an esthesioneuroblastoma that infil-
trated the ethmoidal cribriform plate and their subsequent experience with the
implementation of the approach in a series of esthesioneuroblastomas that do not
require free-flap reconstruction, demonstrating complete tumor removal with no local
recurrences.40 Carrau and colleagues,12 demonstrated that endoscopic-assisted sur-
gery in the treatment of juvenile angiofibromas, was a suitable complement to the
traditional approaches, thus avoiding additional transfacial incisions. In the pediatric
population, this was of particular importance, as it avoided additional interference
with developing facial growth centers and minimized functional and cosmetic deficits.
Castelnuovo and colleagues41 also described the combined cranionasal approach for
en bloc resection of malignant neoplasms with minimal disturbance to the facial skel-
eton. These advantages were similarly echoed by Galassi and colleagues,42 in their
report of the combined cranionasal approach for the resection of infantile myofibroma-
tosis of the ethmoid and anterior ventral skull base. Although most studies have
focused mainly on specific neoplasms, Hanna and colleagues20 reported the use of
the combined cranionasal approach to a wide range of malignant tumors of the sino-
nasal tract. Their study demonstrated that there was no significant difference in
disease-specific or overall survival rate between groups of patients surgically treated
exclusively via EEA and those treated via combined cranionasal approach. This is
probably due to appropriate patient selection for each approach strategy. For
example, smaller, less extensive tumors were selected for EEA, and larger tumors
with significant intracranial extension were selected for a cranionasal approach.
It is important to emphasize that the combined cranionasal approach should be per-
formed only in specialized centers with an experienced skull base team consisting of
an endoscopic/skull base–trained otolaryngologist and neurosurgeon to ensure
optimal success of the operation. When managing malignancies, definitive resection
should, whenever possible, result in complete oncologic removal with tumor-free sur-
gical margins regardless of the approach, as principles of surgical oncology should be
upheld. Although surgery is the mainstay of treatment of most sinonasal and ventral
skull base malignancies, the use of adjuvant or neoadjuvant therapy when appropriate
is critical to achieving optimal oncologic outcomes.20 Advancements in microsurgical
and endoscopic skull base techniques have further added to the armamentarium of
surgical management of sinonasal and ventral skull base malignancies in both the
resection and reconstruction process. The EEA has made great strides in the manage-
ment of anterior ventral skull base malignancies and has consistently yielded good
oncologic outcomes in well-selected patients. When used in conjunction with the
transcranial approach, the combined cranionasal approach is a suitable option in
those with significant intracranial disease, to improve tumor resection and skull
base repair.20 The surgical treatment of sinonasal and ventral skull base malignancies
has evolved to be one of integrated collaboration between the otolaryngologist and
neurosurgeon, necessitating their combined advanced technical expertise and
knowledge.

SUMMARY

Combined transcranial and EEA approaches remain useful in the treatment of sino-
nasal and ventral skull base malignancies. The modified 1-piece extended transbasal
approach provides wide access to the anterior ventral skull base and paranasal
sinuses. The endoscopic endonasal approach has largely replaced transfacial ap-
proaches for combined craniofacial approaches and also can provide additional
344 Liu et al

vascularized tissue for skull base reconstruction, if needed, via the nasoseptal flap.
Double-flap reconstruction with simultaneous vascularized pericranial and nasoseptal
flaps is a useful strategy for malignant tumors that require postoperative adjuvant ra-
diation therapy.

REFERENCES

1. Frazier CH. I. An approach to the hypophysis through the anterior cranial fossa.
Ann Surg 1913;57:145–50.
2. Derome P. Spheno-ethmoidal tumors. Possibilities for exeresis and surgical
repair. Neurochirurgie 1972;18(Suppl 1):1–164 [in French].
3. Tessier P, Guiot G, Rougerie J, et al. Cranio-naso-orbito-facial osteotomies.
Hypertelorism. Ann Chir Plast 1967;12:103–18 [in French].
4. Raveh J, Vuillemin T. Advantages of an additional subcranial approach in the
correction of craniofacial deformities. J Craniomaxillofac Surg 1988;16:350–8.
5. Raveh J, Vuillemin T. Subcranial-supraorbital and temporal approach for tumor
resection. J Craniofac Surg 1990;1:53–9.
6. Kawakami K, Yamanouchi Y, Kubota C, et al. An extensive transbasal approach
to frontal skull-base tumors. Technical note. J Neurosurg 1991;74:1011–3.
7. Sekhar LN, Nanda A, Sen CN, et al. The extended frontal approach to tumors of
the anterior, middle, and posterior skull base. J Neurosurg 1992;76:198–206.
8. Komotar RJ, Starke RM, Raper DM, et al. Endoscopic endonasal compared with
anterior craniofacial and combined cranionasal resection of esthesioneuroblasto-
mas. World Neurosurg 2013;80:148–59.
9. Liu JK, Husain Q, Kanumuri V, et al. Endoscopic graduated multiangle, multicor-
ridor resection of juvenile nasopharyngeal angiofibroma: an individualized,
tailored, multicorridor skull base approach. J Neurosurg 2016;124:1328–38.
10. Devaiah AK, Larsen C, Tawfik O, et al. Esthesioneuroblastoma: endoscopic nasal
and anterior craniotomy resection. Laryngoscope 2003;113:2086–90.
11. Liu JK, Decker D, Schaefer SD, et al. Zones of approach for craniofacial resec-
tion: minimizing facial incisions for resection of anterior cranial base and para-
nasal sinus tumors. Neurosurgery 2003;53:1126–35 [discussion: 1135–7].
12. Carrau RL, Snyderman CH, Kassam AB, et al. Endoscopic and endoscopic-
assisted surgery for juvenile angiofibroma. Laryngoscope 2001;111:483–7.
13. Eloy JA, Vivero RJ, Hoang K, et al. Comparison of transnasal endoscopic and
open craniofacial resection for malignant tumors of the anterior skull base. Laryn-
goscope 2009;119:834–40.
14. Belli E, Rendine G, Mazzone N. Malignant ethmoidal neoplasms: a cranionasal
endoscopy approach. J Craniofac Surg 2009;20:1240–4.
15. Wood JW, Eloy JA, Vivero RJ, et al. Efficacy of transnasal endoscopic resection
for malignant anterior skull-base tumors. Int Forum Allergy Rhinol 2012;2:487–95.
16. Hosemann W, Schroeder HW. Comprehensive review on rhino-neurosurgery.
GMS Curr Top Otorhinolaryngol head Neck Surg 2015;14:Doc01.
17. Zacharia BE, Romero FR, Rapoport SK, et al. Endoscopic endonasal manage-
ment of metastatic lesions of the anterior skull base: case series and literature re-
view. World Neurosurg 2015;84:1267–77.
18. Su SY, Kupferman ME, DeMonte F, et al. Endoscopic resection of sinonasal can-
cers. Curr Oncol Rep 2014;16:369.
19. Terasaka S, Day JD, Fukushima T. Extended transbasal approach: anatomy, tech-
nique, and indications. Skull Base Surg 1999;9:177–84.
 Management of Ventral Skull Base Malignancies 345

20. Hanna E, DeMonte F, Ibrahim S, et al. Endoscopic resection of sinonasal cancers

with and without craniotomy: oncologic results. Arch Otolaryngol Head Neck Surg
2009;135:1219–24.
21. Nicolai P, Battaglia P, Bignami M, et al. Endoscopic surgery for malignant tumors
of the sinonasal tract and adjacent skull base: a 10-year experience. Am J Rhinol
2008;22:308–16.
22. Liu JK. Modified one-piece extended transbasal approach for translamina termi-
nalis resection of retrochiasmatic third ventricular craniopharyngioma. Neurosurg
Focus 2013;34. Video 1.
23. Liu JK, Eloy JA. Modified one-piece extended transbasal approach for resection
of giant anterior skull base sinonasal teratocarcinosarcoma. J Neurosurg 2012;
32(Suppl):E4.
24. Effendi ST, Rao VY, Momin EN, et al. The 1-piece transbasal approach: operative
technique and anatomical study. J Neurosurg 2014;121:1446–52.
25. Liu JK, Christiano LD, Gupta G, et al. Surgical nuances for removal of retrochias-
matic craniopharyngiomas via the transbasal subfrontal translamina terminalis
approach. Neurosurg Focus 2010;28:E6.
26. Kassam AB, Thomas A, Carrau RL, et al. Endoscopic reconstruction of the cranial
base using a pedicled nasoseptal flap. Neurosurgery 2008;63:ONS44–52 [dis-
cussion: ONS52–3].
27. Eloy JA, Kalyoussef E, Choudhry OJ, et al. Salvage endoscopic nasoseptal flap
repair of persistent cerebrospinal fluid leak after open skull base surgery. Am J
Otolaryngol 2012;33:735–40.
28. Liu JK, Schmidt RF, Choudhry OJ, et al. Surgical nuances for nasoseptal flap
reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks af-
ter endoscopic skull base surgery. Neurosurg Focus 2012;32:E7.
29. Eloy JA, Choudhry OJ, Christiano LD, et al. Double flap technique for reconstruc-
tion of anterior skull base defects after craniofacial tumor resection: technical
note. Int Forum Allergy rhinology 2013;3:425–30.
30. Pinheiro-Neto CD, Fernandez-Miranda JC, Wang EW, et al. Anatomical correlates
of endonasal surgery for sinonasal malignancies. Clin Anat 2012;25:129–34.
31. Zweig JL, Carrau RL, Celin SE, et al. Endoscopic repair of cerebrospinal fluid
leaks to the sinonasal tract: predictors of success. Otolaryngol Head Neck
Surg 2000;123:195–201.
32. Eloy JA, Kuperan AB, Choudhry OJ, et al. Efficacy of the pedicled nasoseptal flap
without cerebrospinal fluid (CSF) diversion for repair of skull base defects: inci-
dence of postoperative CSF leaks. Int Forum Allergy Rhinology 2012;2:397–401.
33. Diaz L, Mady LJ, Mendelson ZS, et al. Endoscopic ventral skull base surgery: is
early postoperative imaging warranted for detecting complications? Laryngo-
scope 2015;125:1072–6.
34. Krischek B, Carvalho FG, Godoy BL, et al. From craniofacial resection to endo-
nasal endoscopic removal of malignant tumors of the anterior skull base. World
Neurosurg 2014;82:S59–65.
35. Kopec T, Borucki L, Szyfter W. Fully endoscopic resection of juvenile nasopharyn-
geal angiofibroma: own experience and clinical outcomes. Int J Pediatr Otorhino-
laryngol 2014;78:1015–8.
36. Kennedy DW, Keogh B, Senior B, et al. Endoscopic approach to tumors of the ante-
rior skull base and orbit. Oper Tech Otolayngol Head Neck Surg 1996;7:257–63.
37. Liu JK, O’Neill B, Orlandi RR, et al. Endoscopic-assisted craniofacial resection of
esthesioneuroblastoma: minimizing facial incisions–technical note and report of 3
cases. Minim Invasive Neurosurg 2003;46:310–5.
346 Liu et al

38. Casiano RR, Numa WA, Falquez AM. Endoscopic resection of esthesioneuroblas-
toma. Am J Rhinol 2001;15:271–9.
39. Yuen AP, Fung CF, Hung KN. Endoscopic cranionasal resection of anterior skull
base tumor. Am J Otolaryngol 1997;18:431–3.
40. Yuen AP, Fan YW, Fung CF, et al. Endoscopic-assisted cranionasal resection of
olfactory neuroblastoma. Head Neck 2005;27:488–93.
41. Castelnuovo P, Battaglia P, Locatelli D, et al. Endonasal micro-endoscopic treat-
ment of malignant tumors of the paranasal sinuses and anterior skull base. Oper
Tech Otolayngol Head Neck Surg 2006;17:152–67.
42. Galassi E, Pasquini E, Frank G, et al. Combined endoscopy-assisted cranionasal
approach for resection of infantile myofibromatosis of the ethmoid and anterior
skull base. Case report. J Neurosurg Pediatr 2008;2:58–62.