The Transfrontal Sinus Approach to Anterior Fossa Skull Base Tumors in the Era of Expanded Endonasal Endoscopy

Background: Expanded endoscopic endonasal approaches are being increasingly applied toward resection of anterior fossa skull base tumors. Resection of anterior fossa skull base tumors such as olfactory-groove meningiomas or esthesioneuroblastomas can pose elevated risk for cerebrospinal leak and recurrence due to involvement of paranasal sinuses, the orbit, and vascular and nervous structures. Large midline craniotomies can risk injury to the superior sagittal sinus.

Methods: A retrospective chart review of a series of consecutive patients from a single tertiary academic medical center was performed.

Results: 10 patients (eight females and two males, mean age: 54 years) were identified who underwent surgery by the senior author to address anterior skull base pathology via a transfrontal sinus approach. Patients presented with cognitive decline (n = 4), sinonasal congestion (n = 4), olfactory decline (n = 3), headache (n = 2), proptosis (n = 1), and decline in vision (n = 1). Seven patients underwent transfrontal sinus approach surgery as initial treatment, while three patients had undergone prior endonasal surgical approaches. Nine tumors invaded the ethmoid/cribriform plate, six tumors invaded the frontal sinus, five involved the nasal cavity, four invaded the orbit, and four affected the maxillary sinus. One patient underwent transfrontal sinus approach for the purpose of anterior skull base reconstruction for CSF leak. Pathologies were meningioma (WHO I: n = 1 and WHO: II n = 4), esthesioneuroblastoma (n = 2), neuroendocrine carcinoma (n = 1), squamous cell carcinoma (n = 1), and aneurysmal bone cyst (n = 1). The transfrontal sinus approach included bicoronal incision and harvesting of a pericranial flap. Craniotomies were planned using surgical navigation over the region of the frontal sinus. Five patients underwent transfrontal sinus approach alone, while five patients underwent combined transfrontal sinus, and endoscopic endonasal approach during the same anesthesia event. All patients were reconstructed using pericranium, and 8 of 10 underwent additional abdominal fat graft and alloderm reconstruction. Nine patients had lumbar drains placed preoperatively. Average postsurgical length of hospital stay was 8.3 days. Gross total resection was achieved in seven patients. Two patients underwent adjuvant chemotherapy + radiation, while an additional two underwent adjuvant radiation alone. At mean follow-up of 16 months, no tumor progression has been noted. Visual symptoms improved in both patients affected. One patient suffered complications related to persistent cerebrospinal fluid leak, including infection, hydrocephalus, and hypopituitarism. An additional patient required blood patch for intracranial hypotension related to lumbar drain placement.

Conclusion: Use of a transfrontal sinus approach can yield excellent outcomes, minimize craniotomy size and risk to the superior sagittal sinus, and allow for robust anterior skull base reconstruction to minimize risk of CSF leak. It may be used in combination with an expanded endonasal approach or as a definitive approach depending on clinical circumstances.

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Artikel online veröffentlicht:
12. Februar 2021