Endoscopic Anterior Skull Base Surgery & Sinonasal Tumor Care in Utah
Conditions involving the sinuses and anterior skull base can be difficult to diagnose because they may initially resemble more common sinus, allergy or nasal problems. Some require specialized imaging, endoscopic evaluation or coordination between several medical specialties.
The Ear, Nose and Throat Center of Utah provides specialized evaluation and treatment for cerebrospinal fluid (CSF) leaks, encephaloceles, complex sinonasal masses, inverted papillomas, sinonasal tumors and selected conditions involving the anterior skull base.
Benjamin F. Bitner, MD, is a fellowship-trained rhinologist and endoscopic skull base surgeon with advanced training in minimally invasive approaches to complex conditions involving the nasal cavity, sinuses and anterior skull base.
When appropriate, care is coordinated with neurosurgery, head and neck oncology, ophthalmology, medical oncology, radiation oncology and other specialists.
Benjamin F. Bitner, MD
What Is Endoscopic Anterior Skull Base Surgery?
Endoscopic skull base surgery uses small endoscopes and specialized instruments passed through the nostrils to reach selected conditions involving the nasal cavity, sinuses and skull base.
For appropriately selected patients, an endoscopic endonasal approach may provide access to the affected area without external facial incisions or a traditional open craniofacial approach.
The best surgical approach depends on the diagnosis, location and extent of disease as well as its relationship to the brain, eyes, major blood vessels and other important structures.
Some conditions are best treated entirely through an endoscopic approach, while others require an open operation or a combination of endoscopic and open techniques.
Conditions Treated
Specialized anterior skull base and sinonasal care may be appropriate for patients with:
- Cerebrospinal fluid leaks and CSF rhinorrhea
- Encephaloceles and meningoencephaloceles
- Skull base defects
- Inverted papillomas
- Benign nasal and sinus tumors
- Sinonasal cancers
- Complex or unexplained sinonasal masses
- Selected anterior skull base tumors
- Selected pituitary and anterior skull base lesions treated in collaboration with neurosurgery
- Selected orbital conditions approached through the sinuses
- Persistent unilateral nasal or sinus symptoms
- Masses discovered during nasal endoscopy or imaging
Not every skull base or sinonasal condition requires surgery. An accurate diagnosis is the first step in determining whether observation, additional testing, surgery or multidisciplinary treatment is appropriate.
Dedicated Sinus and Skull Base CT Imaging
Detailed imaging is often important when evaluating skull base defects, complex sinonasal masses and tumors.
Dedicated CT imaging of the sinuses and skull base is available within our clinic and can often be performed the same day when appropriate. High-resolution CT provides detailed information about the sinus and skull base anatomy and can help identify areas of bone loss, skull base defects, previous surgical changes and the relationship of a lesion to surrounding structures.
MRI may also be recommended when additional evaluation of soft tissue, the brain, orbit or other structures is needed.
Having dedicated CT imaging available within the practice can allow imaging to be reviewed directly as part of the rhinology and skull base evaluation.
Cerebrospinal Fluid Leaks
Cerebrospinal fluid (CSF) is the clear fluid surrounding the brain and spinal cord. A cranial CSF leak occurs when an abnormal opening develops between the space surrounding the brain and the nasal cavity or sinuses.
CSF leaks may develop after trauma or surgery, occur in association with increased intracranial pressure or arise spontaneously without an immediately identifiable cause.
One of the most characteristic symptoms is recurrent clear, watery drainage from one side of the nose, sometimes referred to as CSF rhinorrhea. Drainage may increase with changes in position or straining and may be associated with a salty or metallic taste.
Possible signs that warrant evaluation include:
- Repeated clear drainage from one nostril
- Drainage that increases when bending forward or straining
- Salty or metallic-tasting nasal drainage
- Recurrent meningitis
- Persistent or unusual headaches
- Visual symptoms
- Symptoms beginning after head trauma or sinus or skull base surgery
- Imaging showing a possible anterior skull base defect
Clear nasal drainage is common and does not by itself establish the diagnosis of a CSF leak.
Evaluation may include nasal endoscopy, specialized laboratory analysis of collected nasal fluid and detailed CT or MRI imaging. Dedicated sinus and skull base CT imaging can often be performed within our clinic when appropriate.
Because a persistent cranial CSF leak creates an abnormal communication between the sinonasal tract and the space surrounding the brain, identifying and repairing appropriate defects is important.
Dr. Bitner evaluates anterior skull base CSF leaks and performs endoscopic CSF leak repair when appropriate. His research experience includes skull base reconstruction and outcomes following endoscopic skull base surgery
Encephaloceles and Meningoencephaloceles
An encephalocele occurs when brain tissue protrudes through an abnormal opening in the skull. A meningoencephalocele includes brain tissue and its surrounding protective membranes.
When these defects occur along the anterior skull base, tissue may extend into the nasal cavity or sinuses and may be associated with a CSF leak.
Symptoms depend on the location and size of the defect. Some encephaloceles are discovered during imaging, while others may be associated with:
- Clear nasal drainage
- Recurrent meningitis
- Nasal obstruction
- Headaches
- Neurological symptoms
- An abnormality discovered on CT or MRI
Evaluation typically requires detailed imaging and may involve collaboration between rhinology and neurosurgery.
Selected anterior skull base encephaloceles can be repaired through an endoscopic endonasal approach, while the location and extent of other defects may require a different or combined approach.
Persistent One-Sided Nasal or Sinus Symptoms
Many common inflammatory nasal and sinus conditions affect both sides of the nose. Persistent symptoms that remain isolated to one side may require additional investigation.
Causes can include inflammatory disease, dental infection, fungal disease, structural abnormalities and benign or malignant sinonasal masses.
Symptoms that may warrant additional evaluation include:
- Persistent one-sided nasal obstruction
- Recurrent bleeding from one nostril
- Foul-smelling drainage primarily affecting one side
- One-sided facial pressure, swelling or numbness
- Changes in vision or double vision
- Persistent reduction in smell
- A mass discovered in the nose or sinuses
- Symptoms that continue despite appropriate treatment
These findings do not necessarily indicate a tumor. Nasal endoscopy and appropriate imaging can help determine the underlying cause.
Complex Sinonasal Masses
A sinonasal mass is an abnormal growth or lesion involving the nasal cavity or paranasal sinuses. These lesions can be inflammatory, infectious, congenital, benign or malignant.
Examples include:
- Nasal polyps and other inflammatory lesions
- Mucoceles
- Fungal disease
- Inverted papillomas
- Benign sinonasal tumors
- Sinonasal cancers
- Lesions arising from or extending toward the skull base
Because very different conditions can appear similar based on symptoms alone, determining the correct diagnosis is essential before treatment.
Evaluation may include:
- Detailed medical and symptom history
- Nasal endoscopy
- Dedicated CT imaging of the sinuses and skull base
- MRI when indicated
- Biopsy when appropriate
- Pathology review
- Additional laboratory testing or imaging based on the suspected diagnosis
The location and appearance of a mass determine whether biopsy can safely be performed in the office or should occur in an operating room. Certain vascular lesions and masses that may originate from the skull base should be appropriately imaged before biopsy.
Inverted Papilloma
An inverted papilloma is an uncommon sinonasal tumor that is usually benign but can grow locally, recur after treatment and occasionally be associated with malignancy.
Patients may initially experience symptoms similar to other nasal conditions, including:
- One-sided nasal obstruction
- Recurrent nosebleeds
- Nasal drainage
- Reduced sense of smell
- Facial pressure
Evaluation typically includes nasal endoscopy and detailed imaging to determine where the tumor originates and how extensively it involves the surrounding sinuses.
Treatment frequently involves surgical removal, with the surgical approach selected according to the tumor’s site of attachment and extent.
Advanced endoscopic techniques can allow many inverted papillomas to be treated through the nasal passages, while more extensive disease may require additional approaches.
Nasal, Sinus and Anterior Skull Base Tumors
Tumors involving the nasal cavity, paranasal sinuses and anterior skull base are uncommon and represent many different diagnoses. Some are benign but locally aggressive, while others are malignant.
Because these tumors arise near the eyes, brain, cranial nerves and major blood vessels, accurate diagnosis and careful treatment planning are important.
Possible symptoms include:
- Progressive one-sided nasal obstruction
- Recurrent nosebleeds
- Persistent one-sided drainage
- Facial pain, pressure or numbness
- Reduced sense of smell
- Double vision or other visual changes
- Swelling around the nose or eye
- Loose upper teeth or altered dental sensation
- Persistent headaches
- A mass discovered during endoscopy or imaging
Treatment depends on the exact tumor type, location and extent of disease.
Options may include:
- Endoscopic surgery
- Open or combined surgical approaches
- Radiation therapy
- Chemotherapy or other systemic therapy
- Multidisciplinary combinations of treatment
For tumors involving or approaching the anterior skull base, Dr. Bitner may work alongside neurosurgeons, head and neck oncologists and other specialists to develop an individualized treatment plan.
Endoscopic Treatment Options
Endoscopic surgery may be used for selected:
- CSF leaks
- Encephaloceles
- Skull base defects
- Inverted papillomas
- Benign sinonasal tumors
- Sinonasal malignancies
- Anterior skull base lesions
- Selected pituitary or intracranial lesions in collaboration with neurosurgery
The operation is performed through the nasal passages using endoscopes that provide direct visualization of deep sinonasal and skull base anatomy.
In appropriately selected cases, potential advantages of an endoscopic approach include avoiding certain external facial incisions and providing direct access to deep areas of the sinonasal cavity and anterior skull base.
An endoscopic approach is not appropriate for every condition. For some tumors or skull base lesions, an open or combined approach provides safer or more complete access.
The operative approach is selected according to the diagnosis, disease extent, surrounding anatomy and the ability to safely achieve the goals of treatment.
Skull Base and Sinonasal Care with Dr. Benjamin Bitner
Benjamin F. Bitner, MD, is a fellowship-trained rhinologist and endoscopic skull base surgeon specializing in complex disorders involving the nasal cavity, sinuses and anterior skull base.
His clinical interests include:
- Cerebrospinal fluid leaks and CSF rhinorrhea
- Endoscopic CSF leak repair
- Encephaloceles and meningoencephaloceles
- Endoscopic anterior skull base surgery
- Complex sinonasal masses
- Inverted papillomas
- Sinonasal tumors
- Advanced endoscopic sinus and skull base procedures
Dr. Bitner has contributed to peer-reviewed research involving skull base reconstruction, CSF leak outcomes, endoscopic skull base surgery and sinonasal tumors.
Coordinated, Multidisciplinary Care
Anterior skull base disease often crosses traditional specialty boundaries. Depending on the diagnosis, treatment may involve specialists in:
- Rhinology and endoscopic skull base surgery
- Neurosurgery
- Head and neck oncology
- Medical oncology
- Radiation oncology
- Ophthalmology
- Neuroradiology
- Head and neck pathology or neuropathology
This multidisciplinary approach allows the appropriate specialists to contribute to diagnosis, surgical planning, treatment and long-term surveillance.
Research in Skull Base and Sinonasal Surgery
Dr. Bitner has contributed to research addressing several aspects of skull base and sinonasal care, including:
- Skull base reconstruction and tissue sealants
- Recovery following endoscopic skull base procedures
- Lumbar drain use in skull base surgery
- Cerebrospinal fluid leak outcomes
- Sinonasal lymphoma
- Outcomes and healthcare trends involving skull base procedures
Request a Skull Base or Sinonasal Evaluation
A subspecialty evaluation may be appropriate after an abnormal examination or imaging study, a suspected CSF leak, persistent one-sided nasal symptoms or discovery of a complex sinonasal or skull base mass.
Contact the Ear, Nose and Throat Center of Utah to schedule an evaluation with Benjamin F. Bitner, MD.
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