Endoscopic Skull Base Reconstruction: lesson from 420 Cases

Objective: The ability to repair skull base defects resulting from the treatment of different skull base diseases has been a major challenge over the past decade. Aims of the study are to define different endoscopic techniques of reconstruction, focusing on their evolution, and evaluate their efficacy and indications, analyzing their failures. Method: All cases submitted to endoscopic skull base reconstruction from 1995 to 2011 were divided into group A: patients treated for traumatic or non-traumatic CSF-leaks and group B: patients treated for skull base tumors. Patients were fully investigated prior to surgery with endoscopic evaluations and neuroimaging, eventually associated to other in-depth examinations. Results: 420 patients underwent endoscopic skull base reconstruction: 263 in group A and 157 in group B. Primary closure was achieved in 251/263 cases of group A (95.4%) and in 143/157 cases of group B (91.1%). In 26/420 failures (6.2%) revision surgery reached an effective secondary closure of the defect in 100% of cases. Autologous materials were preferred for grafting in both groups, with prevalence for intranasal epithelial and connective tissues (mucoperiostium, bone, cartilage) in group A and for extranasal connective tissue (fascia lata) in group B. Vascularized flaps were employed in selected cases. Indications and details of each technique are provided. Conclusion: The endoscopic technique should be considered a favorable, safe, and minimally invasive procedure for skull base reconstruction with effectiveness rates comparable to external approaches. Failures were related to mistakes in the choice of materials and reconstructive technique, based on the site of the defect and the biology of treated lesions.