Skull base surgery is a precise surgical field dealing with masses and defects in the floor of the skull, where the brain meets the nasal cavity, the orbit, the ear and the neck, and where cranial nerves and major arteries are crowded into a narrow space. It is carried out through different corridors chosen for each case: endoscopically through the nose, through a limited craniotomy, through the ear, or through a combination of these in a shared operation. Conditions managed in this field include meningiomas of the skull base, acoustic nerve tumours, bony and cartilaginous tumours, and tumours arising in the nose or sinuses that extend to the base, as well as cerebrospinal fluid leaks from the nose or ear and certain fractures and complex chronic infections. This work is never directed by one doctor. The plan is formed in a multidisciplinary meeting that brings together the neurosurgeon, ENT or otological surgeon, maxillofacial surgeon, neuroanaesthetist, interventional radiologist, oncologist and specialists in hearing, swallowing and speech. That meeting settles a question more important than the choice of corridor: should surgery come first, or imaging surveillance, or targeted radiotherapy? Candidacy is determined by clinical examination and review of the images, not by reading a web page. The limits must be explained before consent. Complete removal is not a goal to be pursued at any cost. If the tumour is wrapped around a vital artery or nerve, a deliberately partial removal may be planned and completed with radiotherapy, because protecting function outweighs a figure in a report. Surgery does not restore hearing or facial movement already lost, and it cannot guarantee preservation of hearing, facial movement, swallowing or eye movement. Some cases need staged operations, and some small, stable tumours are followed without surgery in selected patients. The practical pathway includes thin-slice CT, MRI and assessment of hearing, vision and hormones, usually a night in the intensive care unit after the operation, and then rehabilitation of swallowing, balance and facial movement where needed.
Procedure steps
- 1
Detailed imaging and the team meeting
Thin-slice CT and MRI are obtained, together with vascular imaging if the tumour lies close to a major artery, plus audiometry and assessment of vision and hormones. The team then discusses every option and records the decision, its rationale and the fallback plan should the findings change during surgery.
- 2
Choosing the corridor and anaesthetic preparation
The corridor chosen is the one that gives the best view with the least brain retraction: endoscopic endonasal, a limited craniotomy, a route through the ear, or a combination. The anaesthetist prepares a plan that controls intracranial pressure and bleeding while still allowing nerve monitoring during the operation.
- 3
Precise bony access and nerve protection
Bone is removed in a calculated amount with fine instruments to create an adequate window without retracting the brain, and cranial nerves and arteries are identified and confirmed with electrical stimulation and neuromonitoring before the tumour is approached.
- 4
Microsurgical removal with functional monitoring
The tumour is separated from nerves and vessels step by step under magnification, and monitoring signals are respected: if they warn of risk to the facial, hearing or swallowing nerves, removal stops at a safe point and the adherent portion is left for a later radiotherapy plan.
- 5
Skull-base reconstruction and recovery in intensive care
The base is reconstructed in layers using the patient's own tissue or grafts to prevent cerebrospinal fluid leak and meningitis. The patient is then monitored in intensive care with assessment of consciousness, facial and eye movement and swallowing, and rehabilitation begins early.
Before the procedure
Bring all your imaging and reports, including old ones, since they show how fast the tumour is growing. Tell the team about every medicine you take, particularly blood thinners, anticoagulants and steroids, and stop nothing on your own. Complete audiometry, eye assessment and hormone tests on time, as they form the baseline against which results are later measured. Treat any dental, sinus or ear infection before the date and report it, especially if the corridor is through the nose. Stop smoking as far as you can, since it impairs healing of the skull-base repair. Ask about the likelihood of an intensive care stay, the plan for swallowing and feeding afterwards, and the expected duration of rehabilitation. Arrange a companion and home support for several weeks, and follow the fasting time before anaesthesia.
After the procedure
Follow your surgeon's instructions to the letter after a nasal corridor: do not blow your nose, sneeze with your mouth open, and avoid straining, lifting, bending and air travel until you are cleared. Start balance exercises and swallowing and speech therapy on schedule, as these genuinely shorten recovery. If eyelid movement or tear production is affected, protect the eye with the prescribed drops and night cover, because a dry cornea damages sight quickly. Eat at the consistency your swallowing therapist specifies and do not rush back to a normal diet. **Seek emergency care immediately** for **clear fluid leaking from the nose or ear**; fever with **neck stiffness, severe headache and dislike of light**; **new drooping of one side of the face**; double or worsening vision; **a change in voice, or repeated choking and coughing when drinking**, which threatens the lungs; sudden hearing loss with severe vertigo; drowsiness or confusion; or wound swelling and discharge.
Expected duration
Usually four to ten hours depending on the corridor and the size of the lesion, generally with a night in intensive care and a typical stay of four to ten days.
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