Comprehensive Postoperative Management After Endoscopic Skull Base Surgery

Key points

Intraoperative considerations

It should be noted that a smoother postoperative recovery with less crusting and fewer issues can be encouraged by certain intraoperative maneuvers. The primary goal of skull base reconstruction is to reestablish a barrier between the sinonasal cavities and the central nervous system. However, a nearly important secondary goal is to use mucosal preservation techniques, similar to the management of inflammatory sinus disease, that maintain ostial patency and prevent scar formation. Meticulous

General postoperative course and care after endoscopic skull base surgery

Postoperatively, most patients are admitted to a neurologic nursing floor. Patients with large skull base defects who require a flap are admitted to a monitored unit (in our practice we use a neurologic step down unit or neurologic intensive care unit) for closer monitoring for at least 1 night. A face tent with mist humidification can provide the patient with comfort. Nasal cannulas are strictly avoided to reduce drying of the nasal mucosa and to prevent the theoretic possibility that applied

Early postoperative care strategies depending on cerebrospinal fluid leak type and reconstruction

The primary goals after skull base surgery are to return the patient to normal functioning as soon as possible and to ensure that the wound is well-healed. The type of skull base reconstruction and the presence and type of CSF leak (low flow or high flow) encountered largely dictate early postoperative management strategies. High-flow CSF leaks, as defined by Patel and colleagues,⁸ are an instance when there is violation of a cistern or ventricle. In general, a multilayered approach for skull

Postoperative care when there is no cerebrospinal fluid leak

There are several options available for reconstructing a skull base defect when there is not an intraoperative CSF leak. This type of closure is done to promote remucosalization of the sellar face and sphenoid sinus cavity and does not have to include multiple layers or extensive packing. The options include, but are not limited to, a free mucosal graft, which can be obtained from a resected middle turbinate or cadaveric acellular tissue (eg, Alloderm, Lifecell, Inc, Branchburg, NJ) followed by

Postoperative care when there is low-flow cerebrospinal fluid leak

A low-flow leak is considered to be any leak that does not involve violation of a cistern or ventricle. The closure in this setting is not dissimilar to the type of closure used in repairing a CSF leak for an encephalocele or iatrogenic defect created after a sinus surgery misadventure. Typically, this includes placement of an underlay graft followed by an overlay graft supported by nasal packing. Options for the underlay graft, which is typically placed in the epidural space, include bone,

Postoperative care when there is a high-flow cerebrospinal fluid leak or a large complex skull base defect

Patients with high-flow CSF leaks generally have more advanced or complex disease and are more challenging to manage postoperatively. All patients with intraoperative high-flow CSF leaks and some patients with complicated or larger defects, particularly those with an exposed carotid artery, warrant the use of a vascularized mucosal flap for the skull base reconstruction. This has been shown to decrease significantly the rate of postoperative CSF leak.8, 12 Like the majority of skull base

Summary

This article summarizes our experience and reviews the current literature on postoperative management after endoscopic skull base surgery. The primary goals after skull base surgery are to return the patient to normal functioning and to ensure that the wound is well-healed and healthy. The type of skull base reconstruction and the presence and type of CSF leak encountered intraoperatively guide postoperative management. Early postoperative care is focused on recognizing complications and