Rarely, patients presenting to the ENT surgeon with anosmia may have an anterior skull base neoplasm such as a meningioma. Historically, the traditional approaches have focused on several transcranial, external routes, including the pterional craniotomy, and the subfrontal craniotomy. The introduction of the endoscope has allowed for minimally invasive approaches to the anterior skull base. This review describes both the supraorbital keyhole approach and the endoscopic endonasal approach. Determining which approach depends greatly on the anatomic and imaging features of the meningioma in question and its relationship to critical neurovascular structures. The endoscopic endonasal approach is a useful alternative for resection of midline tumours extending from the crista galli to the sellar and clival region. The advantages of this approach are early exposure of the tumour and therefore early tumour devascularisation. This approach also avoids brain retraction, is cosmetically more pleasing, and can be performed in candidates with co-morbidities not suited for other invasive approaches. The major disadvantage is the higher rates of post-operative CSF leak. Studies have shown a 20% leakage, and that the more anteriorly the bony resection is extended, the more likely a CSF fistula becomes.

Endoscopic endonasal and keyhole surgery for the management of skull base meningiomas.
Lucas JW, Zada G.
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Gentle Wong

Guy's and St Thomas' Hospitals, UK.

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