Tension Pneumocephalus from Positive Pressure Ventilation Following Endoscopic Skull Base Surgery: Case Series and an Institutional Protocol for the Management of Postoperative Respiratory Distress

Background: Tension pneumocephalus (TP) is a rare but feared complication of endoscopic endonasal skull base surgery. In contrast to simple pneumocephalus, which is common after endoscopic transnasal approaches and managed conservatively, TP represents a neurosurgical emergency and mandates urgent decompression. Case Description: Here we present 2 cases of TP as a consequence of positive pressure ventilation following endoscopic endonasal skull base surgery. Both occurred during resuscitation for postoperative hypoxia. These cases prompted the development of an institution-wide protocol to identify and manage patients at risk of TP after extended skull base approaches. Conclusions: To our knowledge, these are the only such cases of postoperative TP following positive pressure ventilation in the literature.