Endoscopic endonasal resection of anterior skullbase sinonasal tumor, with dural resection and Alloderm button-graft intradural/epidural reconstruction. Left lamina papyracea resected as well. Surrounding dural margins are biopsied and are negative.

Sinonasal malignancy with extension through the anterior skull base and dura

Extension superolateral to the lamina papyracea would require cranial transbasal approach. Involvement/encasement of intracranial vessels would also be more safely managed transcranially.

Endoscope and tower, intraoperative navigation, endoscopic drill, monopolar and bipolar cautery. Patient supine with slight back elevation to reduce venous pressure, and head tilted left for surgeon comfort. Head extended slightly compared to trans-sphenoidal approach. Right thigh prepped for possible fascia lata graft. Possible lumbar drainage.

MRI with high-resolution 3D T1 post-contrast; sinus and neck CT with contrast; PET scan to rule out distant disease.

Lamina papyracea, sphenoid os, sellar face, cribriform plate, anterior and posterior ethmoidal arteries

Advantages: Endoscopic approach provides excellent visualization of the pathology, without need for bicoronal incision.
Disadvantages: Potential for CSF fistula formation is theoretically greater than for transcranial approach with vascularized pericranial graft; inability to clear negative margins over both orbital roofs.

Risks: Spinal fluid fistula, meningitis, injury to anterior cerebral arteries, injury to optic nerve/orbital contents.

Risks: Spinal fluid fistula, meningitis, injury to anterior cerebral arteries, injury to optic nerve/orbital contents.

1. Endoscopic resection of sinonasal cancers. Su SY, Kupferman ME, DeMonte F, Levine NB, Raza SM, Hanna EY. Curr Oncol Rep. 2014 Feb; 16(2):369. PMID: 24445501.