A rational approach to the use of tracheotomy in surgery of the anterior skull base.

OBJECTIVE To offer an algorithm for airway management in anterior skull base surgery. METHODS This is a retrospective review of 109 patients undergoing major anterior skull base surgery from a single senior surgeon's experience from September 1997 to May 2006. RESULTS We report only one (1%) postoperative mortality in this series and only seven major complications in six patients, including two cases of stroke, one case of cerebrospinal fluid (CSF) leak, and four cases of delayed osteoradionecrosis. No patients in this series developed tension pneumocephalus. The total major complication rate is 6%. Fifty-one (47%) patients received prophylactic tracheotomy, and 58 (53%) patients did not receive prophylactic tracheotomy. Eighty-eight (81%) patients received anterior skull base reconstruction with local flaps. Six (5.5%) patients required primary reconstruction with a free flap. CONCLUSION We attribute the very low rate of major complications in this series and, in particular, no cases of tension pneumocephalus and rarity of CSF leaks primarily to prophylactic tracheotomy in selected patients and to a reconstructive strategy that emphasizes use of local vascularized tissue to reconstruct the anterior skull base.