Postoperative protocols following endoscopic skull base surgery: An evidence‐based review with recommendations

Abstract

Background Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence‐based guidance. Methods The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated. Results A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction. Conclusion The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high‐quality studies are needed in order to devise optimal postoperative ESBS protocols.

Skull Base Registries: A Roadmap

“…Although there are many stakeholders in surgical outcomes, physicians must take the lead role in defining how outcomes are assessed as they have the most intimate knowledge of clinical behavior. The outcomes data that are collected should facilitate the development of evidencebased "best practices" and "care pathways" that optimize outcomes and costs, while at the same time preserving our freedom to innovate 5,6 . Such an effort requires consensus, which may be challenging in the field of skull base surgery due to various institutional-related preferences and schools of thought.…”

“…The outcomes data that are collected should facilitate the development of evidencebased "best practices" and "care pathways" that optimize outcomes and costs, while at the same time preserving our freedom to innovate. 5,6 Such an effort requires consensus which may be challenging in the field of skull base surgery due to various institutional-related preferences and schools of thought.…”

Skull Base Reconstruction following Surgical Treatment of Sinonasal Malignancies

“…There are innumerable postoperative protocols following skull base reconstruction with little evidence or consensus surrounding them. 14 It is important to analyze one's own protocols and update them periodically. Three topics in postoperative care will be discussed below.…”

“…They have the ability to add a layer over the reconstruction that holds the repair in place and potentially withstands shifts in intracranial pressure. 14 While they are commonly used, comparable reconstructive outcomes have been suggested with and without dural sealant use. 15 Cumulative experience supports the need for a robust multilayered closure where an intraoperative CSF leak is encountered and, while tissue sealants may be appropriate adjunct in these cases, further research is needed to understand the absolute indications and benefits.…”

“…While nasal packing has been associated with decreased quality of life in the immediate postoperative period, the correlation between nasal packing and postoperative CSF leak is limited, heterogenous, and needs to be further investigated. 14 …”