Comparison of Open and Transnasal Endoscopic Approaches to the Skull Base in the Endoscopic Skull Base Era

Introduction: Selection bias cannot be overemphasized when comparing endoscopic and open skull base series. However, skull base surgery is a rapidly changing field, and it remains imperative to describe the differences in complication rates as the endoscopic approach is utilized for increasingly complex disease and the open approach becomes reserved for the most extensive disease.

Methods: A retrospective chart review revealed 406 patients with 117 open and 338 endoscopic skull base surgeries by a single surgeon from 2008 to 2012. Open and endoscopic complications were compared.

Results: The open cohort consisted of 59% males with a mean age of 50.6 years (range, 1–89 years) and the endoscopic cohort consisted of 53% males with a mean age of 50.3 years (range, 7–86years). Malignancies comprised 57.6% of open cases with 89% stage IV disease and 22.8% of endoscopic cases with 86% stage IV disease. In the open and endoscopic cohorts, 32 and 7% of surgeries, respectively, were performed on patients with prior head and neck radiation. The most common pathology necessitating open surgery was squamous cell carcinoma (35%) and pituitary adenoma was the most common pathology in the endoscopic cohort (23.1%). The open approach was found to have a higher rate of overall postoperative complications (45.8vs.16.9%; p = 0.0001) with significantly higher rates of postoperative infection (23.7vs.3%; p = 0.0001), systemic complications (19.5vs.7.1%;p = 0.0003), and delayed complications (25vs.3.9%;p = 0.0001). Open and endoscopic approaches had similar rates of intraoperative complications (5.1vs.3.0%;p = 0.38) and postoperative cerebrospinal fluid leaks (1.7vs.2.4%;p = 1.0).

Conclusion: Overall complication rates of open approaches were significantly higher than endoscopic approaches. However, open approach patients had a higher stage and grade of histopathology and more frequently required head and neck radiation. Both approaches had similar rates of postoperative CSF leaks. Even as the breadth of the endoscopic approach increases to tackle larger and more invasive disease, open skull base surgery in this series was 26% of surgeries performed by a comprehensive skull base surgeon. The endoscopic era has not made open skull base surgery obsolete but has selected the most complex lesions for open approaches. Therefore, this series is one of the first to describe complication rates in the current state of skull base surgery.