Surgical management of frontal skull base lesions with cerebrospinal fluid rhinorrhea.

Background: Cerebrospinal fluid (CSF) leak, with its potential infectious complications remains today a challenge in diagnosis and surgical treatment. With the introduction of endonasal microsurgery, new minimally invasive techniques for the repair of these defects have been pioneered. Nasal approaches to the anterior skull base include external - transfacial as well as endonasal approaches for reconstruction. It is important to have multiple possible approaches for the correction so that the optimal method for the individual pathology may be selected. The purpose of this paper is to clarify the decision process for selecting the safest procedure with the least possible morbidity and functional compromise. Method: In a retrospective study we assessed a group of 69 patients treated from 1988 to 1996. Patient records, CT scans, postoperative clinical follow-up and a questionnaire, sent to the patients, were evaluated. The various external and endonasal approaches are presented and the closure techniques are discussed in detail. Results: Of the 69 operations, 40 (58%) were external and 29 (42%) were endonasal. There were three failures in the external approach group (4.4%) and no failures in the endonasal group. No major complications in the intraoperative or postoperative course occured. Of importance, olfaction was retained in 94% of patients in at least one side. The average duration of hospitalization was 6 days. Conclusions: Nasal approaches to the anterior skull base for treatment of CSF leaks are highly effective, safe, and cause minimal morbidity. The optimal surgical approach is chosen according to the precise location and extent of the defect. We are now increasing using endonasal microsurgical approaches. The open, transfacial approaches are still indicated for fractures of the posterior wall of the frontal sinus as well as larger multi-fragmented fractures of the anterior skull base.