136

BALKAN MEDICAL JOURNAL

THE OFFICIAL JOURNAL OF TRAKYA UNIVERSITY FACULTY OF MEDICINE © Trakya University Faculty of Medicine
Balkan Med J 2013; 30: 136-41 • DOI: 10.5152/balkanmedj.2013.9112 Available at www.balkanmedicaljournal.org

Invited Review

Surgical Approaches to Resection of Anterior Skull Base and

Paranasal Sinuses Tumors
Sara Abu-Ghanem, Dan M. Fliss

Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School
of Medicine, Tel Aviv University, Tel Aviv, Israel

ABSTRACT
Malignant tumours of the sinonasal tract comprise approximately 3% of the malignancies that arise in the upper aerodigestive tract. Approximately 10%
of tumours that arise in the sinonasal tract originate in the ethmoid and/or frontal sinuses, and are likely to involve the anterior cranial base. The route of
spread of tumours originating in the anterior skull base and paranasal sinuses is determined by the complex anatomy of the craniomaxillofacial compart-
ments. These tumours may invade laterally into the orbit and middle fossa, inferiorly into the maxillary antrum and palate, posteriorly into the nasopharynx
and pterygopalatine fossa, and superiorly into the cavernous sinus and brain. Recent improvements in endoscopic technology now allow the resection of
the majority of benign neoplasms and some early malignant tumours with minor dural involvement. For advanced-stage malignant tumours and benign
tumours with frontal bone involvement, the classical open approaches remain viable surgical techniques. In this paper, we review the open surgical resec-
tion approaches used for resections in the craniomaxillofacial area.

Key Words: Anterior skull base, open approaches, paranasal tumours

Received: 11.03.2013 Accepted: 19.03.2013

Introduction of endoscopic endonasal approaches. Nevertheless, several

problems still exist, relating to case selection, histology, cost,
Tumours involving the anterior skull base and paranasal patient selection, and the experience of the surgeon. This re-
sinuses are challenging to treat because of their relative rarity, view focuses on the open surgical resection approaches used
the wide diversity of tumour types represented, and the vari- for anterior skull base tumours, as used in our institution in
ability in the extent of involved local structures (1). the last 20 years.
The route of spread of these tumours is determined by
the complex anatomy of the craniomaxillofacial compart- Anatomy
ments. These tumours may invade laterally into the orbit and The anterior skull base is a complex anatomical compart-
middle fossa, inferiorly into the maxillary antrum and palate, ment. It can be defined as the portion of the skull base ad-
posteriorly into the nasopharynx and pterygopalatine fossa jacent to the anterior cranial fossa. The anterior skull base
(PPF), and superiorly into the cavernous sinus and brain. Sur- boundaries include the medial border that is formed by the
gery remains the important modality of treatment of anterior cribriform plate, making up the roof of the nasal cavity, the
skull base tumours. Combined craniofacial techniques for the lateral border that is formed by the orbital plates of the fron-
resection of tumours of the anterior skull base were first de- tal bone that form the roof of the orbits and ethmoid air cells,
scribed by Ketcham et al. (2) in 1963. Since then, anterior skull and the posterior border that is formed by the planum sphe-
base surgery has evolved greatly, with a better understanding noidale and lesser wings of the sphenoid (4).
of the anatomy, pathology, imaging and surgical techniques. The cribiform plate is traversed by multiple olfactory
The craniofacial approach and the subcranial approach have nerves that extend from the olfactory mucosa to the olfac-
become the standard of care for the treatment of malignant tory bulbs. A bony fissure between the lesser and greater
tumours involving the anterior skull base (3-6) and, because sphenoid wings, the superior orbital fissure, gives passage to
of this and the varied histologic findings, most outcomes data cranial nerves III, IV, V and VI and to the superior ophthalmic
reflect the experience of small patient cohorts. This Interna- vein. Superior and laterally lies the optic canal bordered by
tional Collaborative study examines a large cohort of patients the body of the sphenoid and by the superior and inferior
accumulated from multiple institutions experienced in cranio- roots of the lesser sphenoid wing, giving passage to the op-
facial surgery, with the aim of reporting benchmark figures tic nerve, ophthalmic artery, and sympathetic nerves. How-
for outcomes and identifying patient-related and tumor-relat- ever, both the superior orbital fissure and optic canal open
ed predictors of prognosis after craniofacial resection (CFR. in the middle cranial fossa and are most commonly affected
Recent developments in technology have allowed the use by central skull base lesions (4). The thin cribiform plate is

Address for Correspondence: Dr. Dan M Fliss, Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery,
Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Phone: +97 236 973 573 e-mail: [email protected]
Balkan Med J Abu-Ghanem and Fliss
2013; 30: 136-41 Anterior Skull Base Surgery
137

easily crossed by tumours; however, the orbital plates of the Weber-Fergusson Incision
frontal bone are made of a thick compact bone that consti- In cases of malignant tumours infiltrating the lateral max-
tutes a barrier to tumour growth into the anterior cranial fossa. illary wall or palate, total maxillectomy is performed via a
Therefore, it is not surprising that most tumours affecting the Weber-Fergusson incision. This approach involves an extenu-
anterior skull base arise from the sinonasal region. ation of the lateral rhinotomy incision that includes splitting
of the upper lip. The Weber-Fergusson incision permits com-
Preoperative Evaluation and Anaesthesia plete exposure of the maxilla, from the upper alveolar ridge
All patients scheduled for operation are evaluated preop- to the orbit. This allows exposure of the superior and inferior
eratively by a head and neck surgeon, a neurosurgeon, an an- aspects of the maxilla and its complete en bloc resection. The
aesthesiologist, and a reconstructive plastic surgeon. Patients soft tissue of the cheek is raised from the anterior surface of
younger than 18 years are also examined by a paediatrician. In the maxilla, transecting the infra-orbital nerves and vessels
the past decades, cross-sectional imaging has become a key should the superior and lateral walls of the maxilla need to
factor in the management of skull base pathology. CT and MRI be approached. An upper cheek flap is developed laterally
have a complementary role in the evaluation of skull base pa- and superiorly up to the level of the inferior orbital rim and
thology and are often used together to determine the full ex- the maxillary tuberosity. Inferiorly it can reach the pterygo-
tent of a lesion (4). In recent years, positron emission tomog- maxillary fossa.
raphy (PET), often combined with CT, has become popular.
PET/CT useful for determining the staging of the disease and Lynch Incision
identifying residual or recurrent disease (5, 7). Angiography is The Lynch incision is rarely used nowadays as a sole ap-
rarely used nowadays for diagnostic purposes. Highly vascular proach but rather, it is used as an extension of the Weber-Fer-
lesions, such as juvenile angiofibroma or paraganglioma, can gusson incision. This incision extends along the lower border
be diagnosed with angiography. Angiography is also used for of the eyebrow or in a skin crest along the upper lid, allowing
therapeutic purposes in the case of preoperative embolisation it to be concealed at the hair-skin junction. If the incision is
and balloon occlusion test. made inside the eyebrow, it may leave a thick and noticeable
scar, giving inferior cosmetic results. The incision is extended
Open Surgical Approaches for the Anterior Skull Base down, ~0.5 cm medial to the medial cantus. It can be extend-
Adequate exposure of the anterior cranial base for exci- ed laterally up to the level of the lateral cantus, or inferiorly to
sion of neoplasms traditionally requires a combined intracra- be included in a lateral rhinotomy incision.
nial and extracranial approach. Most commonly, a team of
neurosurgeons and otolaryngologists performs this proce- Dieffenbach Incision and Its Modifications
dure. The choice of an extracranial approach depends on the The Dieffenbach incision and its modified forms are used
site and extent of the tumour and aesthetic considerations, to approach tumours involving the infra-orbital rim and zygo-
as well as the experience of the surgeon with particular ap- matic root. It can be extended up to the level of the medial
proaches. cantus, or inferiorly, to be included in a lateral rhinotomy in-
The extent of exposure of these approaches include the cision. The classical Dieffenbach incision extends along the
frontal sinus anteriorly, the clivus posteriorly, the frontal lobe lower border of the eyelid, along a skin crest. The incision
superiorly, and the paranasal sinuses, the pterygo-maxillary extends from the medial cantus to the lateral cantus. A later
fossa and infratemporal fossa inferiorly. The lateral boundaries modification of this incision is the subcilliary incision, which
of this approach include both superior orbital walls. is performed just below the cilia of the eyelid, or the mid-
cilliary incision, performed halfway between the Dieffenbach
Transfacial Approaches and subcilliary incisions.
The superior border of the flap includes the infra-orbital
Lateral Rhinotomy Incision rim and orbit; its inferior border is the anterior maxillary wall;
The lateral rhinotomy approach is used in the case of a laterally it is extended to expose the maxillary tuberosity and
malignant tumour originating in the nasal cavity and maxillary root of the zygoma; and medially it extends to the nasal bone.
sinus without palatal invasion. Benign tumours with anterior In elderly and previously irradiated patients, the redundant
maxillary wall involvement are similarly approached. This ap- skin and subcutaneous tissue of the lower eyelid tend to swell
proach allows wide exposure of the maxillary antrum, nasal as the incision may include the lymphatic drainage of this area.
cavity, ethmoidal sinuses, and sphenoid sinus. The facial inci- The skin is closed with a subcutaneous, continuous number
sion extends along the lateral border of the nose, ~1 cm lat- 5.0 prolene stitch to prevent contraction of the thin skin in this
eral to the midline. It starts from the cephalad medial cantus area. This incision is also almost exclusively used in conjunc-
and extends down through the skin crest bordering the nasal tion with other transfacial skin incisions.
ala. It is continued towards the filtrum. The flaps can be devel-
oped to the level of the maxillary tuberosity laterally, the up- Midfacial Degloving (MFD)
per gingival sulcus inferiorly, the frontal sinus and infra-orbital The MFD approach combines the sublabial incision used
rim superiorly, and to the nasion (suture between the frontal in external approaches to sinus surgery with the intranasal
and nasal bones) and nasal septum medially. incision used in cosmetic rhinological surgery. The main ad-
 Abu-Ghanem and Fliss Balkan Med J
Anterior Skull Base Surgery 2013; 30: 136-41
138

Figure 2. The craniofacial approach. A Weber-Fergusson

incision (right) and coronal incision (left) are shown
base and paranasal sinuses (3, 10, 11). This technique incorpo-
rates a combination of transfacial and transcranial procedures
in order to allow broad exposure of the anterior cranial fossa
and subcranial compartment. Initially, a lateral rhinotomy is
made, followed by a medial maxillectomy, anterior and posteri-
or ethmoidectomy and sphenoidectomy, which are preformed
under a microscope. The cribriform plate and frontal recess
are exposed along with the lamina papyracea bilaterally. Next,
the elevation of the coronal flap and frontal craniotomy is per-
formed. The craniotomy includes the frontal bone from the
level of the glabela below, to roughly 4-5 cm above the skull
base superiorly. The lateral borders of the craniotomy are the
midpupillary line bilaterally. Next, the dura is incised, if indi-
cated, and the frontal lobes are retracted superiorly, exposing
the anterior skull base from above. The final stage of the oper-
ation includes resection of the tumour, which extends through
the cribiform plate in a combined fation from below and above.
Figure 1. Facial incisions for the resection of craniofacial The use of craniofacial surgery has been documented for a
neoplasms: lateral rhinotomy, Weber-Ferguson, and mid- variety of malignant and benign tumours. This technique has
ciliary. Combined approaches are possible two major advantages: (i) it affords broad exposure of the an-
vantage of this approach over conventional lateral rhinotomy terior skull base from above and below, providing excellent
or Weber-Ferguson approaches is avoidance of facial incision. access to the orbital, spheno-ethmoidal and paranasal cavi-
ties; and (ii) resection of intradural and extradural tumours can
This approach was originally designed for benign tumours,
be performed in a single procedure that allows precise recon-
including inverted papilloma, juvenile angiofibroma, odonto-
struction of the dura. Despite the technical reproducibility of
genic cysts, and benign fibro-osseous lesions (8). Nowadays,
the craniofacial approach, this procedure still involves a high
MFD has been largely replaced by the endonasal approach as
risk of postoperative complication. The main limitation of this
the main technique for extirpation of these lesions. Neverthe-
approach is the need for frontal lobe retraction, which may
less, it can be used for large tumours involving the anterior
lead to encephalomalacia, brain oedema, and subdural bleed-
skull base, in conjunction with an ‘upper’ approach, or after
ing, especially in the elderly population, and the presence of
the failure of an endonasal resection. The MFD approach in-
cosmetic inconvenience because of the transfacial skin inci-
volves a complete transfixation incision, with a complete in- sions (Figure 2).
tercartilaginous incision. This effectively separates the upper
lateral cartilage from the lower lateral cartilage, the latter of The Subcranial Approach
which is later included with the superiorly retracted flap. Next, The subcranial approach is a single-stage procedure used
a ‘degloving’ of the facial soft tissue from the nasal skeleton for tumours involving the anterior skull base (12, 13). The extent
and maxilla is preformed. This is achieved through a sublabial of exposure with the subcranial approach includes the frontal
incision that extends from first molar to first molar. We have sinus anteriorly, the clivus posteriorly, the frontal lobe superior-
popularised the use of MFD in conjunction with the subcranial ly and the paranasal sinuses inferiorly. Laterally, the boundaries
approach in order to restore the skull base tumour excision in of this approach are both superior orbital walls. The subcranial
its inferior-lateral and posterior extension (9). Figure 1 sum- approach has several major advantages: (i) it affords direct ex-
marises the surgical transfacial approaches. posure of the anterior skull base from anterior to posterior in-
stead of from above and below, as in the craniofacial approach;
Craniofacial Resection (ii) it allows simultaneous intradural and extradural tumour re-
The craniofacial resection is a well-established technique moval from anterior to posterior; (iii) it does not require facial
for the surgical excision of tumours involving the anterior skull incision; and (iv) minimal frontal lobe manipulation is required.
Balkan Med J Abu-Ghanem and Fliss
2013; 30: 136-41 Anterior Skull Base Surgery
139

a b
Figure 3. The subcranial approach. a) Intraoperative view showing the elevation of coronal and pericranial flaps and oste-
otomies (right). b) Nasofrontal bones after subcranial resection can be tailored according to the location and dimension
of the anterior skull base
The subcranial approach involves a coronal incision and oste- noid roofs, the cribiform plate, the temporal fossa, and the
otomy of the naso-fronto-orbital bone segment, which allows parasellar area.
access to the intra- and extra-cranial compartments of the an-
terior skull base (Figures 3a and 3b). The main disadvantage In Combination with the MFD Approach
of this approach is bone osteonecrosis post radiotherapy in The subcranial MFD approach is used for resecting benign
cases of malignant tumours (14). tumours involving the anterior skull base and the inferior, lat-
eral, and posterior planes of the maxillary sinus. This is indi-
The Subcranial Approach and Combinations cated mainly for the resection of juvenile angiofibromas with
Although both the subcranial and craniofacial approaches anterior skull base invasion (9). It can be also combined with
permit complete tumour resection in the majority of cases, an orbitozygomatic or pterional approach for tumours that ex-
situations still arise in which the inferior, lateral or posterior tend to the lateral skull base (Figure 4).
aspects of the tumour are not adequately exposed. These in-
clude neoplasms with extensions to the hard palate caudally, In Combination with the Le Fort I Approach
to the cavernous sinus posteriorly, to the orbital apex, PPF, or The subcranial-LeFort I approach allows a wide exposure
infratemporal fossa (ITF) laterally, and to the nasopharynx and of the tumour from the cribriform area to the lower part of
clivus inferoposteriorly. Such cases require a combination of the clivus, maxillary sinuses, and nasal cavity. It is indicated
the standard subcranial approach with other approaches as a only for selected cases that cannot be approached by the
one-step procedure to allow proper exposure and tumour ex- subcranial approach or combined endoscopic-subcranial ap-
proach. This approach may be selected for the extirpation of
tirpation. In these combined approaches, a second approach
large chordomas or chondrosarcomas originating in the clivus,
may include one or more of the following procedures: MFD,
which extend superiorly to the sphenoid sinus, planum sphe-
orbito-zygomatic, transfacial, Le-Fort I, or the transorbital ap-
noidale, and cribriform plate.
proach. These combined approaches require additional inci-
sions and osteotomies, according to the type and extent of
In Combination with the Transorbital Approach
the tumour.
A combined transcranial-transorbital approach is used for
malignant tumours that penetrate the bony orbit and periost
In Combination with the Pterional Approach
and infiltrate the anterior orbital content (T4a) or orbital apex
This approach is a combination of the subcranial approach (T4b) (12). A coronal flap is performed and the flap is extended
and the pterional approach (15). A unilateral pterional ap- inferiorly in one side of the coronofacial flap (Figures 5a and 5b).
proach is added to the subcranial approach to expose the or- The superior and medial walls of the orbit are exposed and
bit, the retro-orbital region, or the ITF. Large central nervous stripped from their periostium. During dissection along the
system tumours with extracranial extent, such as meningio- medial orbital wall, the anterior and posterior ethmoidal arter-
mas involving the orbit or upper nasal and sinus cavities, can ies are identified and clipped. If the roof or medial orbital wall
also be resected via this combined approach. In this modi- is involved by the tumour, they are removed at this stage. If
fication, the coronal incision is preformed and the skin flap they are not involved, the upper and lower lids may be spread,
elevation continues down to the level of the fat pad overlying allowing future insertion of an orbital implant and an improved
the zygoma, above the temporalis fascia. On the ipsilateral cosmetic result. If the lids are involved, a circular skin incision
side, the reminder of the dissection dips below the level of the is made along the superior and inferior orbital rims and the
temporalis fascia from the horizontal line above the arch and skin of the lids is kept on the main specimen.
continues as a fasicocutaneous flap. The muscle is detached
anteriorly and superiorly, exposing the temporal fossa. The Conclusion
next stage includes osteotomies in both frontal and pterional
regions. The standard osteotomy described above is modified Anterior skull base surgery is a young discipline that origi-
by its extension laterally, to include a portion of the orbital nated only half a century ago. Detailed knowledge of skull
roof and temporal bone. The bone segment is then removed base anatomy is a prerequisite for correct imaging diagnosis
in one or two pieces, exposing the orbital, ethmoid and sphe- and for accurate delineation of the extent of skull base lesions.
 Abu-Ghanem and Fliss Balkan Med J
Anterior Skull Base Surgery 2013; 30: 136-41
140

Figure 4. The subcranial-midfacial degloving (MFD) combined approach. Intraoperative view (middle and left) and CT
scan post surgery (right) are shown

a b

Figure 5. a) Intraoperative view for the subcranial-transorbital combined approach. b) The subcranial-transorbital
combined approach. Postoperative CT scans (middle and left) and general appearance (right) are shown
The outcome of anterior skull base surgery has improved Some issues such as disease extension over the orbit and
steadily over the years. In a systematic review by Dulgerov et into the orbit, extensive dural resection, and piecemeal exci-
al. (16), the overall disease-free survival in sion are still to be resolved.
The 1960s was 28±13%, where as in the 1990s it had Ethics Committee Approval: N/A.
improved to 51±14%. To date, the best outcome studies of
Informed Consent: N/A.
these tumours are from the International Collaborative Study,
which published their results most recently in 2006 (1, 3, 17, Peer-review: Externally peer-reviewed.
18). In this multicentre case series, in which our institution Author contributions: Concept - S.A-G., D.M.F.; Design - S.A-G.,
was included, data from 1307 patients were acquired retro- D.M.F.; Supervision - D.M.F.; Resource - S.A-G., D.M.F.; Materials -
spectively. Analysis of patient data from 1956-2000 showed S.A-G., D.M.F.; Data Collection&/or Processing - S.A-G., D.M.F.; Anal-
a 5-year overall survival of 54%, including preoperative or ad- ysis&/or Interpretation - S.A-G., D.M.F.; Literature Search - S.A-G.,
juvant radiotherapy or chemotherapy, and an operative mor- D.M.F.; Writing - S.A-G., D.M.F.; Critical Reviews - D.M.F.
tality of 4.3% was reported. Reduced 5-year overall survival Conflict of Interest: No conflict of interest was declared by the authors.
was associated with invasion of the orbital contents or brain,
Financial Disclosure: No financial disclosure was declared by the authors.
mucosal melanoma pathology, previous radiotherapy or che-
motherapy, the presence of positive surgical margins, and the
presence of comorbidities (1). References
Although open surgical resection remains the gold stan-
1. Patel SG, Singh B, Polluri A, Bridger PG, Cantu G, Cheesman AD,
dard for the removal of anterior skull base lesions, recent data
et al. Craniofacial surgery for malignant skull base tumors:report
indicate that endonasal endoscopic surgery is safe and is as-
of an international collaborative study. Cancer 2003;98:1179-87.
sociated with acceptable outcomes in patients with benign 2. Ketchman AS, Wilkins RH, Vanburen JM, Smith RR. A combined
and early malignant neoplasms (5). With advancements in im- intraacranial facial approach to the paranasal sinuses. Am J Surg
aging, diagnostic technology, diagnostic pathology, surgical 1963;106:698-703.
technology and instrumentation, reconstructive techniques, 3. Ganly I, Patel SG, Singh B, Kraus DH, Bridger PG, Cantu G, et al.
and rehabilitation, it is expected that endoscopic approaches Craniofacial resection for malignant paranasal sinus tumors:Report
will evolve to round out the operative armamentarium. of an International Collaborative Study. Head Neck 2005;27:575-84.
Balkan Med J Abu-Ghanem and Fliss
2013; 30: 136-41 Anterior Skull Base Surgery
141

4. Gil Z, Fliss DM. Tumours of the skull base and paranasal sinuses. 12. Fliss DM, Abergel A, Cavel O, Margalit N, Gil Z. Combined sub-
1st ed. Byword Books. 2011. cranial approaches for excision of complex anterior skull base
5. Mehta RP, Cueva RA, Brown JD, Fliss DM, Gil Z, Kassam AB, et al. tumors. Arch Otolaryngol Head Neck Surg 2007;133:888-96.
What’s new in skull base medicine and surgery? Skull Base Com- 13. Fliss DM, Zucker G, Amir A, Gatot A, Cohen JT, Spektor S.
mittee Report. Otolaryngol Head Neck Surg 2006;135:620-30. The subcranial approach for anterior skull base tumors. Op-
6. Gil Z, Fliss DM. Pericranial wrapping of the frontal bone af- erative Techniques in Otolaryngology-Head and Neck Surgery
ter anterior skull base tumor resection. Plast Reconstr Surg 2000;11:238-53.
2005;116:395-8. 14. Fliss DM, Gil Z, Spektor S, Leider-Trejo L, Abergel A, Khafif A,
7. Gil Z, Even-Sapir E, Margalit N, Fliss DM. Integrated PET/CT sys- et al. Skull base reconstruction after anterior subcranial tumor
tem for staging and surveillance of skull base tumors. Head Neck resection. Neurosurg Focus 2002;12:e10.
15. Zucker G, Nash M, Gatot A, Amir A, Fliss DM. The combined
2007;29:537-45.
subcranial-pterional approach to the anterolateral skull base. Op-
8. Margalit N, Wasserzug O, De-Row A, Abergel A, Fliss DM, Gil
erative Techniques in Otolaryngology-Head and Neck Surgery
Z. Surgical treatment of juvenile nasopharyngeal angiofibroma
2000;11:286-93.
with intracranial extension. Clinical article. J Neurosurg Pediatr
16. Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra
2009;4:113-7.
T. Nasal and paranasal sinus carcinoma:are we making prog-
9. Fliss DM, Zucker G, Amir A, Cohen JT, Gatot A. The combined ress? A series of 220 patients and a systematic review. Cancer
subcranial-midfacial degloving approach. Operative Techniques 2001;92:3012-29.
in Otolaryngology-Head and Neck Surgery 2000;11:279-85. 17. Ganly I, Patel SG, Singh B, Kraus DH, Bridger PG, Cantu G, et
10. Mantravadi AV, Zender CA. Craniofacial approaches to the an- al. Complications of craniofacial resection for malignant tumors
terior skull base. Operative Techniques in Otolaryngology-Head of the skull base:report of an International Collaborative Study.
and Neck Surgery 2010;21:181-7. Head Neck 2005;27:445-51.
11. Fliss DM, Zucker G, Cohen A, Amir A, Sagi A, Rosenberg L, 18. Ganly I, Patel SG, Singh B, Kraus DH, Bridger PG, Cantu G, et
et al. Early outcome and complications of the extended sub- al. Craniofacial resection for malignant melanoma of the skull
cranial approach to the anterior skull base. The Laryngoscope base:report of an international collaborative study. Arch Otolar-
1999;109:153-60. yngol Head Neck Surg 2006;132:73-8.