Closure of cerebrospinal fluid leaks prevents ascending bacterial meningitis

INTRODUCTION: Endoscopic surgery of the anterior skull base has become the standard procedure for the repair of cerebrospinal fluid (CSF) leaks of various origins. Closure of the leaks is believed to prevent ascending meningitis, although no report has specifically shown this. MATERIAL AND METHODS: Retrospective chart study of 39 patients who underwent endoscopic skull base surgery from 1/1993 to 11/2002. SETTING: Tertiary University Hospitals. OUTCOME MEASUREMENT: Incidence of ascending meningitis after endoscopic skull base repair in patients with anterior skull base defects associated or not with meningitis and CSF leak. RESULTS: Forty-one endoscopic repairs of anterior skull base defects of various origins were performed in 39 patients. Fifteen (36.5%) had suffered bacterial meningitis before surgery. Mean follow-up was 65 months (range 22-120). The defect was repaired using an "underlay" technique with lyophilized dura (n=11) or fascia lata (n=30), and covered with free mucosal grafts from either the middle or the inferior turbinates. Closure was achieved in 40/41 cases at first attempt. No recurrence of ascending bacterial meningitis was observed during follow-up in any of the fifteen patients who had previously presented with a CSF leak or skull base defect with meningitis. Also, no new bacterial meningitis occurred in all other patients. One case of meningoencephalocele of the lateral sphenoid wall developed a recurrent CSF fistula associated with bacterial meningitis two years after endoscopic repair, requiring endoscopic revision surgery. No patient received vaccination in this series. DISCUSSION: Closure of active CSF leaks and reconstruction of skull base defects without CSF-leak in patients with prior ascending bacterial meningitis seem to provide excellent long-term results with neither recurrence of ascending meningitis nor incidence of meningitis in the other patients, unless a CSF leak re-appears. Conservative treatment of CSF leaks may lead to bacterial meningitis, therefore surgical closure of leaks or defects at the skull base should be considered treatment of choice to prevent ascending meningitis.     

Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms

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.     

Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks

OBJECTIVE: To analyze possible etiological factors of spontaneous cerebrospinal fluid (CSF) rhinorrhea and to assess the outcomes of endonasal endoscopic repair. DESIGN: Retrospective study. SETTING: Academic neurosurgical hospital.Patients Twenty-one consecutive patients who presented with spontaneous CSF leak and underwent endonasal endoscopic surgery from January 1999 through December 2001. INTERVENTION: Preoperative examination included computed tomographic scans; nasal endoscopy; measurement of glucose concentration in the nasal discharge; and, in some cases, cisternographic evaluations via computed tomography and/or magnetic resonance imaging. Telescopes, conventional endoscopic sinus surgery instruments, and a microdebrider were used for all patients who underwent endonasal surgery. A combination of plastic materials, ie, abdominal fat, fascia lata, rotated middle turbinate flaps, and fibrin glue, were used for fistula repair. RESULTS: At the time of surgery, CSF fistulas were found in the cribriform plate (6 patients), in the fovea ethmoidalis (6 patients), and in the sphenoid sinus (9 patients). In 5 of the 6 patients who had an extremely pneumatized sphenoid sinus, the source of the leak was located in the lateral extension of the sinus. A meningocele protruding through the bone defect was the source of the leak in 10 patients. Postoperative follow-up lasted from 9 to 42 months, and 20 patients were considered cured. There was only 1 recurrence, in a patient whose CSF rhinorrhea originated in the deep lateral recess of an overpneumatized sphenoid sinus. Thus, the overall success rate was 95.2%. There were no postoperative complications. CONCLUSIONS: Possible etiological factors of this disease include obesity, congenital malformations of the skull base, an overpneumatized sphenoid sinus (particularly in its lateral extensions), and the empty sella syndrome. Endoscopic endonasal repair of spontaneous CSF rhinorrhea appears to be a safe and successful procedure. However, techniques for endoscopic closure of CSF fistulas in the lateral part of the sphenoid sinus need further perfecting.     

Radial forearm free tissue transfer in the management of persistent cerebrospinal fluid leaks

OBJECTIVE: Cerebrospinal fluid (CSF) leaks can occur after head trauma or skull base surgery. Persistent or spontaneous leaks should be repaired, since they put patients at risk for serious intracranial complications. Although numerous repair methods have been successful, the occasional patient develops a persistent leak. We describe our experience with free tissue transfer for repair of recalcitrant CSF leaks. STUDY DESIGN: Retrospective chart review of patients undergoing free tissue transfer for repair of a CSF leak between November 1995 and October 2004. Setting was an academic, tertiary care referral center. METHODS: Twelve patients with persistent CSF leak were studied. Eleven of 12 patients had undergone a previous repair attempt ranging from endoscopic repair with fat graft to craniotomy and primary repair of the dural defect. All patients underwent radial forearm free tissue transfer. RESULTS: There were six female and six male patients. Average age was 52.7 years (range, 22-80 y). The most common presenting complaints were intracranial abscess, recurrent meningitis, or pneumocephalus (n=9) and CSF otorrhea or rhinorrhea (n=8). Cause was head trauma (n=6), prior surgery (n=4), cholesteatoma (n=1), or meningoencephalocele (n=1). Eleven of 12 patients failed prior procedures (range, 0-6 procedures; mean, 1.9). Ten flaps were placed in the anterior skull base and two were in the middle or posterior skull base. Radial forearm free tissue transfer resulted in sustained resolution of CSF leakage in all 12 patients. CONCLUSIONS: Free tissue transfer is an efficacious option in the repair of recalcitrant CSF leaks.     

Manejo de las fístulas nasales de líquido cefalorraquídeo según su tamaño. Nuestra experiencia

ObjectiveWe present our experience in the reconstruction of cerebrospinal fluid (CSF) leaks according to their size and location.Material and methodsFifty-four patients who underwent advanced skull base surgery (large defects) and 62 patients with CSF leaks of different origin (small and medium-sized defects) were included. Large defects were reconstructed with a nasoseptal pedicled flap positioned on fat and fascia lata and lumbar drainage was used. In small and medium-sized leaks of other origin, intrathecal fluorescein 5% was applied previously to identify the defect. Fascia lata in an underlay position was used for reconstruction, which was then covered with mucoperiosteum from the turbinate. Perioperative antibiotics were administered for 5-7 days. Nasal packing was removed after 24-48 hours.ResultsThe most frequent aetiology for small and medium-sized defects was spontaneous (48.4%), followed by trauma (24.2%), iatrogenic (5%) and others. The success rate was of 91% after the first surgery and 98% in large skull base defects and small/medium-sized respectively. After rescue surgery, the rate of closure achieved was 100%. The follow-up was 15.6 ± 12.4 months for large defects and 75.3 ± 51.3 months for small/medium-sized defects without recurrence.ConclusionsEndoscopic surgery for closure of any type of skull base defect is the gold standard approach. Defect size does not play a significant role in the success rate. Fascia lata and mucoperiosteum allow a reconstruction of small/medium-sized defects. For larger skull base defects, a combination of fat, fascia lata and nasoseptal pedicled flaps provide a successful reconstruction.     

Localization and infliction pattern of iatrogenic skull base defects following endoscopic sinus surgery at a teaching hospital

Objective

Aim of this study is to evaluate the incidence, infliction patterns and management of dural injuries with cerebrospinal fluid (CSF) rhinorrhea following endoscopic sinus surgery at a teaching hospital. We present our results of over 14 years of experience from endoscopic repair of CSF rhinorrhea with long-term follow-up.

Methods

A retrospective study was performed by screening 14 years of sinus surgeries for iatrogenically inflicted CSF leaks of the anterior skull base. Obtained data were analyzed to determine the infliction pattern and location of CSF leaks, surgical closure techniques and outcomes. All incidences were further evaluated with regards to the surgeons training status.

Results

144 patients out of 6908 sinus surgeries were diagnosed with CSF rhinorrhea and underwent subsequent surgical repair. 52 patients had iatrogenic CSF leaks with 32 of the defects inflicted by the department's physician personnel. Average follow-up was 62 months, with a range of 10–168 months. The side distribution was 56.3% to the patient's right side and in 40.6% to the patient's left side. 68.7% became apparent during the initial surgery whereas 31.3% only after surgery. The most common defect location was the anterior ethmoid at the attachment of the medial concha base with 43.7%, followed by the junction between the ethmoid and sphenoid sinus with 21.9%, the frontal sinus aditus with 18.7% and the medial ethmoid region with 9.4%. With increasing training status, surgeons were more prone to cause defects at the frontal sinus aditus whereas surgeons with lesser training status caused more defects at the anterior ethmoid at the medial concha base. The posterior ethmoid and sphenoid sinus was equally prone to defects over all stages of surgical training. Initial endoscopic repair was successful in 87.5% of patients and 95% after revision surgery.

Conclusion

The obtained data confirm the safety of the endonasal sinus surgery according to Wigand's technique. The incidence of iatrogenic CSF leaks at a teaching hospital is not higher than at specialized rhinology departments. We observed a distinct pattern of inflicted skull base defects with different hot-spot areas, prone to damage in various stages of the surgeon's status of expertise.     

First experience with transnasal and transseptal endoscopic and microscopic repair of anterior skull base CSF fistulae

Currently, endoscopic endonasal surgery is a valuable and safe procedure routinely performed for treatment of paranasal sinus disorders. Since the endoscopic technique has become popular in this area, interest has been increased in its possible use for some other indications such as transsphenoidal pituitary and anterior skull base surgery. In this paper, we present our experience in using the nasal endoscope for repair of anterior skull base cerebrospinal fluid (CSF) fistulae. Between 1994-1999, we observed 44 patients with CSF rhinorrhea. Out of 44 patients, 34 had improved with the conservative treatment in two weeks, in 10 patients endoscopic surgery was performed and in one patient endoscopic surgery failed and the defect was repaired with transsphenoidal microscopic surgery. The remaining 9 patients were doing well and no problem was encountered concerning the surgery.     

外伤性迟发性脑脊液鼻漏的诊断和治疗

目的 探讨外伤性迟发性脑脊液鼻漏的发病原因及临床诊治特点.方法 回顾性分析中山大学附属第一医院院2000-2008年收治的13例外伤≥3个月后出现脑脊液鼻漏患者的临床资料,重点分析术前CT及MRI扫描的结果 ,结合术中所见,分析两者之间的关系.结果 13例患者颅底均有陈旧性骨折,MRI扫描显示其中11例有软组织自颅底缺损处疝入鼻窦.术中鼻内镜检查见骨质缺损最小约为0.1 cm×0.2 cm;最大约为1.2 cm×1.5 cm,漏口部位与CT检查结果 一致,其中11例漏口处可见暴露的硬脑膜及坏死组织.所有病例均采用经鼻内镜下脑脊液鼻漏修补术,术后随访12～36个月,未见复发.结论 脑膜组织经颅底缺损疝入鼻窦为外伤后脑脊液鼻漏迟发的关键因素,CT、MRI检查有助于明确漏口位置,其治疗宜采用鼻内镜下脑脊液鼻漏修补术.     

Cerebrospinal fluid leakage after gamma knife radiosurgery for skull base metastasis from renal cell carcinoma: a case report

We report a rare case of cerebrospinal fluid (CSF) leakage after radiosurgery for skull base metastasis from renal cell carcinoma. A mass invading the left petrous bone and sphenoid sinus was treated with gamma knife radiosurgery, and CSF rhinorrhea developed 4 months after the procedure. The CSF leak was successfully controlled by endoscopic sinus surgery. CSF leakage may develop as a rare complication after radiosurgery for skull base lesions, and the endoscopic repair technique is a useful therapeutic method.     

鼻内镜下自体材料脑脊液鼻漏修补术(附16例临床分析)

目的 评价采用自体材料经鼻内镜脑脊液鼻漏修补术的手术方法和治疗效果。 方法 回顾性分析2010年至2015年诊断为脑脊液鼻漏的16例患者的临床资料。所有患者行鼻内镜下脑脊液鼻漏修补术,其中自发性6例,外伤性5例,医源性5例。采用的修补材料有颞肌、颞肌筋膜、中鼻甲黏膜、中鼻甲骨、鼻中隔黏膜、下鼻甲黏膜、阔筋膜、腹部脂肪、钩突黏膜等,均为自体材料。 结果 16例患者中,一次修补成功15例, 二次手术修补成功1例。术中及术后均未发生严重并发症。 结论 鼻内镜下自体材料脑脊液鼻漏修补术是一种安全、有效和微创的手术方式,成功率高。术前准确的漏口定位、选择合适的手术入路和适宜的修补材料是手术成功的关键。     

Endoscopic Repair of Cerebrospinal Fluid Fistulae and Encephaloceles

The authors review their experience with endoscopic repair of skull base defects associated with cerebrospinal fluid (CSF) rhinorrhea and/or encephaloceles involving the paranasal sinuses. Between January 1991 and December 1995, 51 patients were evaluated for anterior and middle cranial fossa defects at a tertiary care facility. Of these patients, 36 underwent endoscopic repair of skull base defects. Factors related to surgical success were analyzed. These factors included etiology, defect location, number of prior attempts at repair, type of graft(s) used, fluorescein use, complications, durations of lumbar drain placement, and duration of CSF leakage prior to repair. During the first attempt, successful endoscopic repair was accomplished in 34 (94.4%) of the 36 patients. The mean duration of follow-up was 24.6 months, with a range of 2 to 57 months. The authors conclude that an endoscopic approach provides a safe and effective means for repairing many skull base defects.     

Endoscopic repair of cerebrospinal fluid leaks after neurosurgical procedures

OBJECTIVES: Endoscopic repair of cerebrospinal fluid (CSF) leaks has proven to be effective and safe. CSF rhinorrhea is a well-known complication of neurosurgical procedures in the anterior cranial fossa. We present a series of endoscopic repairs of CSF rhinorrhea secondary to neurosurgical procedures. STUDY DESIGN: Retrospective review of 13 cases. METHODS: Thirteen patients are included in the study. Eleven had CSF leaks after hypophysectomy, one after clipping of an anterior circle of Willis aneurysm, and one after posttraumatic frontal lobe debridement. Leaks were identified intraoperatively during the neurosurgical procedure (n = 8) or with intrathecal fluorescein injection during a separate procedure (n = 5). Repair was performed by exposing the skull base defect, debriding the defect margins, and sealing the defect with a free mucosal graft or abdominal fat. RESULTS: Leaks were identified in the sphenoid (n = 12) and posterior ethmoid (n = 1) sinuses. Nine patients had lumbar drains placed. One patient had recurrence of CSF rhinorrhea 2 months after initial repair requiring a revision procedure. No other recurrences were noted. One patient developed postoperative meningitis requiring intravenous antibiotics and a prolonged hospital stay. No other postoperative complications were observed. CONCLUSIONS: Endoscopic repair is a safe and effective treatment for CSF rhinorrhea encountered as a neurosurgical complication.     

Endoscopic management of cerebrospinal fluid rhinorrhea

PURPOSE: Most anterior skull base defects causing cerebrospinal fluid (CSF) rhinorrhea can be readily approached using endoscopic techniques when surgical repair is necessary. We present our data from endoscopic repair of CSF rhinorrhea with long-term follow-up. METHODS: Retrospective data analysis of patients that were diagnosed with anterior skull base CSF rhinorrhea and underwent endoscopic repair at a tertiary institution. Data were analyzed to determine the etiology and location of CSF leaks. Diagnostic techniques, surgical techniques, and surgical outcomes were reviewed. RESULTS: Ninety-two patients were diagnosed with CSF rhinorrhea and underwent endoscopic repair over a 12-year period. Forty-eight were males, and 44 were females. The average age was 49 (range 6-81) years. Average follow-up was 25 months, with a range of 12 to 82 months. The etiology of CSF leak was prior endoscopic sinus surgery in 23 patients (25%), idiopathic in 19 (21%), neurosurgery in 17 (18%), trauma in 18 (20%), and the presence of meningocele/encephalocele in 11 patients (12%). The most common location of the defect was the sphenoid sinus (n = 36, 39%), followed by ethmoid roof (n-27, 29%), and cribriform plate (n = 24, 26%). Endoscopic repair was initially successful in 78 (85%) patients. Seven additional patients underwent successful revision endoscopic repair for an overall success rate of 92% (n = 85). Five (6%) large skull base defects were eventually repaired by neurosurgery using open intracranial techniques. No major complications were encountered. CONCLUSION: The intranasal endoscopic approach is an effective and safe technique in the surgical management of anterior skull base CSF rhinorrhea. Long-term success rate in our patient population was 92%.     

Endoscopic management of cerebrospinal fluid leaks

To examine the diagnosis and treatment of patients with cerebrospinal fluid (CSF) rhinorrhea, a cohort of 36 patients treated between 1993 and 2000 were examined to consider the role of imaging and other diagnostic tests such as the presence of beta-transferrin in nasal secretion. The etiology of the condition was considered and was found to be congenital in 7 patients and acquired in 29 patients of which in 15 patients it was traumatic, in 12 patients it occurred spontaneously, and in 2 patients it was associated with Wegener's granulomatosis. Where it was possible to obtain nasal secretion, beta-transferrin proved a highly sensitive and specific test and imaging included computed tomography (CT), CT cisternography, and magnetic resonance imaging (MRI) of which fine detail coronal CT and MRI proved the most helpful. In six patients neither imaging nor beta-transferrin could be used to confirm the diagnosis in which case intrathecal fluorescein was used. Repair was performed endoscopically in all cases with one exception where the defect was felt to be too large for this technique. Middle turbinate mucosa, cartilage, and fascia were the preferred repair materials in the anterior skull base whereas dermalfat was preferentially used in the sphenoid. The overall success rate for an endoscopic approach was 94% although in three cases a second endoscopic procedure was required to produce closure and external approaches were used in two additional patients. The use of a diagnostic algorithm is helpful in both confirming the presence of CSF rhinorrhea and the optimum approach. In the vast majority of cases an endoscopic repair will be successful and it avoids many of the complications associated with craniotomy, particularly in a young population. Therefore, it is our preferred option, although surgeons must be prepared for alternative procedures should these prove necessary.     

带蒂鼻中隔黏膜瓣在侵及前颅底鼻腔鼻窦恶性肿瘤切除术颅底重建中的应用

目的　回顾性分析应用带蒂鼻中隔黏膜瓣修复内镜下切除侵及颅底鼻腔鼻窦恶性肿瘤术后颅底缺损的效果。方法　2008年9月～2016年5月内镜下切除侵及颅底鼻腔鼻窦恶性肿瘤31例,应用以鼻后中隔动脉和筛前-筛后动脉为供血的两种类型带蒂鼻中隔黏膜瓣,修复重建前颅底切除后较大颅底缺损。结果　31例患者前颅底重建均一次性修补成功。1例肿瘤复发二次手术患者术后发生脑脊液漏,给予椎管置管引流1周愈合;1例术后10 d撤出鼻腔填塞物后出现脑脊液鼻漏,颅内感染3例,余无颅内出血或血肿等并发症发生。术后随访3～66个月见黏膜瓣愈合良好,无移植瓣膜坏死和脑膜脑膨出发生。结论　血管化带蒂鼻中隔黏膜瓣是内镜颅底外科的一种首选的、可靠的前颅底修补用材料。     

Cerebrospinal fluid rhinorrhoea—Transnasal endoscopic repair

The recent advances in nasal endoscopic surgery in anterior skull base area have made it the procedure of choice for repair of cerebrospinal fluid rhinorrhoea (CSFR). The aim of the present study is to analyze the technique and efficacy of endoscopic repair of CSFR.     

Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea

The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery. The clear anatomical exposure of the roof of the nasal and paranasal sinus cavities by the endoscope offers the surgeon a golden chance to identify the area of CSF leak, and thus enables one to adequately plan the management. The aim of this work is to evaluate the use of facia lata sandwich graft technique for endoscopic endonasal repair of CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were treated endoscopically using 2 layers of facia lata (underlay and onlay) interposed with a layer of septal cartilage or conchal bone in-between (sandwich technique) for repair. Fifty-five percent of cases were regarded as spontaneous CSF leaks with no obvious cause, 30 % following head injury and 15 % were iatrogenic. The ethmoidal roof was the commonest location of CSF leak (60 %) followed in frequency by the cribriform plate and the sphenoid sinus (20 % each). Follow-up period was 12–24 months. We have achieved a 95 % success rate in managing CSF leaks in our 40 patients in the first attempt repair and 100 % success rate after second attempt repair. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high success rate and avoid the morbidity associated with craniotomy. Using the three-layer, sandwich-grafting technique of facia lata further adds more security to the sealing of CSF and augments the results of repair.     

Endonasal endoscopic repair of cerebrospinal fluid leaks of the sphenoid sinus

BACKGROUND: Multiple reports have demonstrated the efficacy of the transnasal endoscopic repair of cerebrospinal fluid (CSF) leaks of the anterior cranial base. The literature, however, lacks a comprehensive clinical study specifically addressing the transnasal endoscopic repair of CSF leaks of the sphenoid sinus. OBJECTIVE: To ascertain the factors that significantly affect the surgical outcome after transnasal endoscopic repair of CSF leaks of the sphenoid sinus. METHODS: We retrospectively reviewed the medical records of all patients who underwent an endoscopic transnasal repair of CSF leaks of the sphenoid sinus at our teaching hospitals. RESULTS: Twenty-four patients with CSF leaks of the sphenoid sinuses that were repaired by the transnasal endoscopic approach were included in our study. Causes of the CSF leaks included trauma, surgery, neoplasms, and idiopathic causes. Obliteration was the most common technique used to repair the CSF fistulas (used in 15 [58%] of 26 procedures). Grafting materials included banked pericardium, mucosa, turbinate bone, and mucoperichondrium placed by underlay or onlay grafting or abdominal fat used to obliterate the sphenoid sinus. Twenty-two patients were successfully treated on the first attempt. A persistent leak in 2 patients with previously unrecognized high-pressure hydrocephalus was repaired during a second endoscopic surgery, quickly followed by ventriculoperitoneal shunting. CONCLUSIONS: Assuming an adequate repair, other factors such as the cause, the size of the defect, the technique and material used to repair the defect, and perioperative management do not affect the surgical outcome significantly. Untreated high-pressure hydrocephalus can lead to a recurrence or persistence of the leaks and should be suspected in patients with posttraumatic, idiopathic, or recurrent CSF leaks.     

Anterior skull base trauma during endoscopic sinus surgery for nasal polyposis preferred sites for iatrogenic injuries

OBJECTIVE: To determine typical locations for traumatic lesions of the anterior skull base during endoscopic sinus surgery. STUDY DESIGN: In this retrospective study 12 patients were included who had undergone endoscopic sinus surgery for nasal polyposis and were referred to the author for revision surgery after iatrogenic trauma of the anterior skull base during the procedure. Each patient had been operated by a different surgeon, all of the physicians being in an advanced stage of their surgical career and being board certified otolaryngologists. RESULTS: During endoscopically controlled revision surgery, all lesions could be detected, 10 of them being located in the ethmoid roof, while one injury had occurred in the lateral lamella of the cribriform plate and another one in the olfactory groove between the medial turbinate and the nasal septum. CONCLUSION: In contrast to reports in the literature, the preferred site for anterior skull base injuries during endoscopic sinus surgery in our group was not the lateral lamella of the cribriform plate, but the anterior part of the ethmoid roof, just behind the frontal recess. Apparently the course of the ethmoid roof might be misinterpreted during sinus surgery even by surgeons who are familiar with the operative technique.     

Transglabellar, transorbital approach for anterior skull base tumors

Transglabellar, transorbital approach through the bottom of the frontal sinus for tumours invading anterior skull base in presented. Exposure was improved by rhinectomy and lateral swing of the nose. The most common tumours in the group of 11 patients were squamous cell carcinoma (4) and olfactory neuroblastoma (4). Skull base was excised en block with partial maxillectomy in 8 patients and with total maxillectomy in 3 patients. Orbitectomy was performed in 6 cases. Dura defect was closed with fascia lata and fibrin glue. No serious complications after surgery developed. Rhinoscopy and computed tomography demonstrated clear cavity and no dura prolapse. Transglabellar, transorbital approach provides good exposure for anterior skull base tumours excision and repair.