Can Skull Base Reconstruction at the Cribriform Plate Sustain CPAP Use

Introduction: Recent studies have established that the use of continuous positive airway pressure (CPAP) is safe following endoscopic pituitary surgery. In contrast, endoscopic reconstruction at the anterior skull base (ASB), particularly at the level of the cribriform plate (CP), requires more robust techniques, given the anti-gravity orientation of this region. This cadaver study tests different reconstruction methods to assess safety at the CP. Methods: Three fresh fixed cadaver heads were used. Nasoseptal flap (NSF), temporoparietal fascia flap (TPF), and pericranial flap (PCF) were harvested in each cadaver at the start of dissection following which complete endoscopic sinus surgery (ESS) with type 3 frontal drillout and CP resection was performed. A window was created into the frontal bone to assess transmission of CPAP pressure into the cranium. Each flap was separately placed and CPAP then started at ramp pressures of 4 cm of H2O. About 5 cc of saline was introduced into the cranial window and CPAP was started. Appearance of bubbles was deemed as an indicator of air leak through the flap. Results: Critical differences in pressure tolerance were observed among flap types. The nasoseptal and temporoparietal fascia flaps demonstrated uniform failure at 4 cm H2O pressure in all cadaveric specimens. In contrast, the pericranial flap showed variable performance: failure occurred at 4 cm H2O in specimens 1 and 2, while specimen 3 maintained integrity up to 8 cm H2O. No flap configuration sustained pressures above 8 cm H2O. Conclusion: Standard CPAP pressures (typically 5–20 cm H2O) may compromise the integrity of ASB reconstructions at the CP. While PCF demonstrated superior but inconsistent pressure tolerance compared with NSF and TPF, further studies are required to assess reconstruction techniques following ASB surgery at CP with larger sample sizes to establish clear guidelines for CPAP use in this patient population. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany