Reconstruction of the anterior skull base: lessons learned

CSF leak is a serious condition caused by an abnormal communication between the subarachnoid space and the nasal cavity or paranasal sinuses. It may result from traumatic injuries, surgical complications, tumors, or spontaneous skull base defects. If not diagnosed and managed properly, CSF leaks can lead to life-threatening complications such as bacterial meningitis and recurrent infections. Prompt identification and appropriate repair are critical to prevent these adverse outcomes

with advances in endoscopic techniques, the management of CSF leaks has shifted from open cranial procedures to minimally invasive endonasal approaches. Endoscopic skull base surgery offers improved visualization, reduced morbidity, shorter hospital stays, and excellent cosmetic results compared to traditional transcranial methods. It has become the gold standard for most anterior and middle skull base CSF leak repairs.

the primary objective of this presentation is to provide a comprehensive overview of the endoscopic management of CSF leaks. The lecture will cover the common etiologies of CSF leaks—including traumatic, iatrogenic, and spontaneous cases—and the clinical signs such as clear rhinorrhea, positional headache, and recurrent meningitis. The importance of a thorough diagnostic workup will be emphasized, particularly the role of beta-2 transferrin testing, high-resolution CT scans, MRI, and CT cisternography. Intrathecal fluorescein may also be discussed as a valuable tool for intraoperative localization of the leak site

surgical indications will be clearly defined, with a focus on factors such as the size and location, flow rate of the leak, and associated anatomical variations. Step-by-step surgical techniques will be demonstrated, including debridement, identification of the defect, and closure using various grafting materials such as fat, fascia lata, and synthetic dural substitutes. The use of multilayer repair strategies will be highlighted for high-flow or large defects

intraoperative tools, including angled endoscopes, image-guided navigation, and micro-instruments, significantly enhance surgical precision

participants will gain insight into the management of complex or recurrent leaks, complications such as pneumocephalus and infection, and long-term follow-up protocols. Success rates for endoscopic repair are generally high, with over 90% success reported in experienced hands

this session targets ENT surgeons, neurosurgeons, rhinologists, residents, and skull base surgery teams. It aims to equip attendees with practical knowledge and surgical strategies for effective, safe, and long-lasting management of CSF leaks through endoscopic techniques

in conclusion, endoscopic repair of CSF leaks is a safe and highly effective technique that has become the preferred method for most skull base defects. A multidisciplinary approach, careful patient selection, and adherence to surgical principles are key to achieving optimal outcomes and preventing recurrence. CSF leak is a serious condition caused by an abnormal communication between the subarachnoid space and the nasal cavity or paranasal sinuses. It may result from traumatic injuries, surgical complications, tumors, or spontaneous skull base defects. If not diagnosed and managed properly, CSF leaks can lead to life-threatening complications such as bacterial meningitis and recurrent infections. Prompt identification and appropriate repair are critical to prevent these adverse outcomes.

CSF leakage may develop during endoscopic sinus surgery. I would like to share my experience in this issue.

This narrated video illustrates the endoscopic endonasal approach for surgical repair of a spontaneous ethmoid roof meningoencephalocele. The surgical sequence of the procedure, starting with endoscopic identification of the meningoencephalocele and concluding with the reconstruction of the bony anterior skull base, will be demonstrated. The intraoperative findings that influence the key steps taken in this procedure will be discussed. In appropriately selected patients, the endoscopic endonasal approach provides an effective method to surgically treat a spontaneous ethmoid roof meningoencephalocele.

the outcome objectives for the audience are to (1) recognize the presentation of sinonasal meningoencephaloceles based on symptoms, nasal endoscopy, and diagnostic imaging; (2) understand the surgical sequence in the endonasal repair of an ethmoid roof meningoencephalocele; and (3) appreciate the feasibility of the endoscopic approach to surgically manage spontaneous ethmoid meningoencephaloceles.