Skull Base Surgery Frequently Asked Questions

The skull base (or cranial base) is the part of the skull (cranium) that supports the brain and separates it from the rest of the head.

Blood vessels to the brain and cranial nerves from the brain run through holes in the skull base. Below the skull base are the nasal passages, sinus cavities, facial bones, and muscles that assist with chewing.

Traditionally, neurosurgeons treated conditions that arose within the skull. Ear, nose, and throat doctors (otolaryngologists) or head and neck surgeons treated those that arose in the head outside the skull.

Because tumors and other diseases that affected the skull base or deep facial tissues were hard to reach, a number of surgical specialties joined forces to deal with these problems. Now, a wide range of specialists works as a team to treat these skull base tumors.

The skull base surgery team may include:

• Neurosurgeons
• Head and neck surgeons
• Plastic surgeons
• Eye surgeons (ophthalmologists)

There are three stages to skull base surgery:

1. The surgical approach for reaching the tumor
2. Resection to remove the tumor
3. Reconstruction

There are many ways to approach the skull base. In the past, the favored method was to approach the skull base from above (transcranial approach) and below (transfacial approach) at the same time.

The transcranial approach consists of a scalp incision followed by a craniotomy (removing part of the skull). Surgeons then lift the brain up to reach the skull base. They may also temporarily remove the bones of the facial skeleton to increase access to the skull base. The transfacial approach consists of incisions on the face or inside the mouth that provide access to the sinus cavities and skull base from below.

Working from both sides of the skull base, surgeons can then remove tumors that are at the skull base. Surgery results in a defect of the skull base and dura (thick lining over the brain) that surgeons must repair to prevent leakage of spinal fluid and infection (meningitis).

Over the last decade, UPMC has pioneered new methods that allow surgeons to perform most skull base surgeries through the nasal passages using an endoscope — a small lighted device that looks inside a body cavity. Called the Endoscopic Endonasal Approach (EEA), surgeons can perform all three stages of skull base surgery (approach, resection, and reconstruction) through the nose without the need for scalp or facial incisions.

Surgeons at UPMC's Center for Skull Base Surgery have experience in all types of skull base surgery. They use a range of surgical approaches and techniques to design the best treatment for your diagnosis.

If your doctor at the UPMC Center for Skull Base Surgery recommends surgery, you may first need:

• Medical clearance from your primary doctor or anesthesiologist
• To visit with other specialists on the skull base surgery team
• Further medical testing or CT and MRI scans

Surgeons may schedule some procedures in two stages on two separate days. The first stage includes the tumor exposure. Several days later, during the second stage, the surgeon will remove the tumor.

For a routine surgery, surgeons will place plastic splints in the nasal passage. Splints will remain for a few weeks after surgery.

They will also fill your nasal passage with either compressible packing or a balloon catheter. This remains in place for up to one week, depending on the extent of your surgery. Someone on your care team can easily remove the packing or catheter before discharge or in the office if already discharged. Once doctors remove the nasal packing, they will instruct you to spray the nasal cavity with saline (salt water) several times per day.

For one month after surgery, you will need to avoid activities that increase pressure of spinal fluid inside the head to reduce the risk of a spinal fluid leak.

Some things to avoid include:

• Bending
• Lifting
• Straining
• Blowing your nose

A spinal fluid leak is characterized by the drainage of clear fluid from the nose. If doctors confirm a spinal fluid leak, they can repair most cases using endoscopic surgical techniques.

For several months after skull base surgery, most people notice a decrease in smell and taste due to decreased airflow through the nose. This will often improve as healing occurs.

Your doctor at UPMC's Center for Skull Base Surgery will see you every few weeks initially to perform an endoscopic exam of the nasal cavity and remove nasal crusts. By three to four months, healing is usually complete and crusting diminishes. Additional follow up depends on your diagnosis, symptoms, and need for more therapy.