PNA Medical Corner: Endoscopic Skull-Base Surgery

This month the PNA Medical Corner features the International Consensus Statement on Endoscopic Skull-Base Surgery, as presented in an article published in the International Forum of Allergy and Rhinology. The ICAR: ESBS was produced collaboratively by dozens of experts, several of whom are members or longtime friends of the PNA. Those include Drs. Theodore Schwartz, John Jane, Jr., Daniel Kelly, James Liu, Daniel Prevedello, Fred Gentili, James Evans, and Juan Fernandez-Miranda.

ICAR: endoscopic skull-base surgery.

Wang EW1, Zanation AM2, Gardner PA1, Schwartz TH3, Eloy JA4, Adappa ND5, Bettag M6, Bleier BS7, Cappabianca P8, Carrau RL9, Casiano RR10, Cavallo LM8, Ebert CS Jr2, El-Sayed IH11, Evans JJ12, Fernandez-Miranda JC13, Folbe AJ14, Froelich S15, Gentili F16, Harvey RJ16,17, Hwang PH13, Jane JA Jr18, Kelly DF19, Kennedy D5, Knosp E20, Lal D21, Lee JYK5, Liu JK4, Lund VJ22, Palmer JN5, Prevedello DM9, Schlosser RJ23, Sindwani R24, Solares CA25, Tabaee A3, Teo C26, Thirumala PD1, Thorp BD2, de Arnaldo Silva Vellutini E27, Witterick I16, Woodworth BA28, Wormald PJ29, Snyderman CH1.

1 University of Pittsburgh, Pittsburgh, PA.
2 University of North Carolina, Chapel Hill, NC.
3 Weill Cornell, New York, NY.
4 Rutgers University, Newark, NJ.
5 University of Pennsylvania, Philadelphia, PA.
6 Hospital of Barmherzigen Brueder, Wien, Germany.
7 Harvard University, Boston, MA.
8 University of Naples, Naples, Italy.
9 Ohio State University, Columbus, OH.
10 University of Miami, Miami, FL.
11 University of California San Francisco, San Francisco, CA.
12 Jefferson University, Philadelphia, PA.
13 Stanford University, Stanford, CA.
14 Michigan Sinus and Skull Base Institute, Royal Oak, MI.
15 Lariboisiere University, Paris, France.
16 University of Toronto, Toronto, Canada.
17 University of New South Wales, Sydney, Australia.
18 University of Virginia, Charlottesville, VA.
19 Pacific Neuroscience Institute, Santa Monica, CA.
20 Medical University of Vienna, Vienna, Austria.
21 Mayo Clinic, Scottsdale, AZ.
22 University College London, London, United Kingdom.
23 Medical University of South Carolina, Charleston, SC.
24 Cleveland Clinic, Cleveland, OH.
25 Emory University, Atlanta, GA.
26 Prince of Wales Hospital, Randwick, Australia.
27 University of Sao Paulo, Sao Paulo, Brazil.
28 University of Alabama Birmingham, Birmingham, AL.
29 Adelaide and Flinders Universities, Adelaide, Australia.



Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).


Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.


The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.


A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
© 2019 ARS-AAOA, LLC.


CSF rhinorrhea; angiofibroma; clival chordoma; craniopharyngioma; endoscopic endonasal approach; endoscopic endonasal skull-base surgery; esthesioneuroblastoma; evidence-based medicine; meningioma; nasoseptal flap reconstruction; olfactory neuroblastoma; pituitary adenoma; squamous cell carcinoma


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