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Objective: to optimize surgical tactic of endoscopic endonasal transsphenoidal (EET) approaches in cases of tumors with intra-and extracranial extension.Material and methods. For the period of 2013-2019, we retrospectively reviewed 39 patients with tumors of intra-extra skull base location or just extracranial extension. Tumor location and pathology: tumors in pterygopalatine fossa (paraganglioma, carcinoma, neurilemmoma, neurofibroma, chondrosarcoma) -10 (25.6 %), pituitary adenomas with sphenoid sinus and/or parasellar extension -14 (35.9 %), sphenoid sinus tumors (carcinoma, neurilemmoma, fibrous dysplasia, angiofibroma, esthesioneuroblastoma) -8 (20.5 %), petroclival tumors -6 (15.4 %): hemangiopericytoma -1, clival tumors -5 (chordoma), sella turcica lesion with posterior clinoid recess extension (osteoma) -1 (2.5 %). The extended EET approaches used were as follows: EET + transpterygoid approach -22 (56.4 %) (in 4 (18.1 %) cases transmaxillary approach was additionally used), extended EET + transclival approach -4 (10.2 %), EET + transcavernous approach -2 (5.1 %), EET + transethmoidal approach -11 (28.2 %). In all cases, we used Karl Storz rigid 4mm 18cm with 0 and 30-degree angled optics. The extent of resection was determined based on routine postoperative CT scans performed within 24 hours after surgery. The volume of resection was evaluated using gadolinium. Gross total resection was defined as the resection of 100 % of the target lesion, subtotal resection as less than 100 % volumetric reduction of the lesion on postoperative CT scans. Further follow-up was done in three, six months and 1 year after surgery, then annually by MRI scanning with gadolinium.Results. Gross total resection was achieved in 7 (77.8 %) cases of tumor in pterygopalatine fossa. In cases of pituitary adenomas with Knosp 3, Knosp 4 cavernous sinus extension, gross total resection was achieved in 7 (53.8 %) individuals. Sphenoid sinus tumors were totally removed in 5 (62.5 %) cases. Subtotal resection was achieved in 11 (28.2 %) cases. Partial resection was achieved in 8 (20.5 %) cases. Postoperative complications were observed in 5 (12.1 %) cases. ConclusionsTransethmoidal extended endoscopic endonasal approach is sufficient and good to access the anterior wall of the cavernous sinus improving visualization and better removing of cavernous sinus pathology extension. Transpterygoid extended endoscopic endonasal approach provides sufficient visualization of pterygopalatine fossa, petroclival region. Transmaxillary extension allows reaching the subtemporal region.

Introduction: The problem of choosing surgical approach in the treatment of CSF leak is the subject of discussion depending of the location and the size of the bone defect of the skull base. Materials and methods: 37 patients with nasal CSF leak were treated. In 17 cases, nasal CSF leak was caused by meningo(encephalo)cele. Spontaneous nasal cerebrospinal fluid occurred in 14 cases. In 3 cases, nasal CSF leak was the result of traumatic brain injury (in one case, the cause of nasal CSF leak was post-traumatic meningoencephalocele of the frontal sinus); in the other 3 cases there was postoperative wound nasal cerebrospinal fluid. Results and discussion: Groups of patients were formed depending on the use of vascularized or moved (free) flaps: 1). Multilayer plastics of bone defects of the anterior and middle cranial fossae using displaced (free) flaps. 2). Multilayer plastic of bone defects of the anterior and middle cranial fossa using a nasoseptal flap or middle nasal concha on the leg. In all cases (100%) nasal CSF leak was eliminated. External lumbar drainage was performed in 6 patients and only in cases where the plastic of the bone defect was performed by displaced free flaps. Conclusions: 1). The use of endoscopic endonasal techniques is a minimally invasive method to close skull base bone defects (including large – more than 20 mm) in the area of the anterior and middle cranial fossae. 2). Subcranial approaches are expedient, effective and technically more convenient for nasal CSF leak defects of the frontal sinus and defects in the anterior cells of the etmoid bone.3). Vascularized flaps is expedient for plastic at middle (11-20 mm) and big (more than 20 mm) bone defects of skull base.