Preoperative imaging to define the extent of the disease and in particular the extent of any intracranial involvement is vital. Surgery to resect lesions in this area should be done where there are the expertise and the facilities to do a craniotomy if necessary or to deal
with any intracranial complications, although these should be rare.
Otologists are familiar with the dura, both operating next to it and dealing with it when it is damaged. Rhinologists may be less comfortable dealing with exactly the same problems, but tears to the dura are readily dealt with (see section on the management of CSF leaks in Chapter 15, p. 240). The main surgical principles are:
• Define the extent of the lesion (this in part relies on radiology).
• Establish a preoperative plan that will enable the lesion to be removed safely, but also anticipate what problems may be faced and how they might be dealt with. For example, an anterior skull base defect may be created that is larger than might have been desired. Ideally patient consent should be obtained in such a way that they have been warned of this possibility. A graft of fascia or chondral or septal cartilage may be needed to close any defect.
• Gain surgical control by defining the margins of the lesion.
• Do not grab and twist any bone attached to the anterior skull base—including the lesion—as this may fracture the skull base unpredictably.
• Reconstruct any defect (see the sections Management of Skull Base Lesions with a CSF Leak and En-cephaloceles, Chapter 15).
• Bleeding and reduced visibility are the main causes of poor surgical technique. It is worth taking time and using topical vasoconstrictors such as 1: 10000 epinephrine on a neurosurgical patte or 1 cm ribbon gauze. Sections of the cribriform plate or fovea ethmoidalis can be removed, and it is best if the dura is preserved. It is important to use a fenestrated sucker and not to apply anything but minimal suction to brain tissue if it is exposed. Careful dissection, avoiding trauma that might produce intracranial bleeding, and respecting the dura will allow the resection of tumors that involve the skull base if their removal is indicated. • Patients having surgery of this type should give fully informed consent.
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