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Gopi G, Sarkar S, Mohakud S, Patnaik A, Bansal S, Preetam C, Sahu RN, Parida PK. Study on Closure of Skull Base Defect Post-Endoscopic Endonasal Transsphenoid Pituitary Surgery: A Novel Flap Design. J Neurol Surg B Skull Base 2019; 82:313-320. [PMID: 34026407 DOI: 10.1055/s-0039-3400224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022] Open
Abstract
Objective This study was aimed to compare the closure of skull base defect in endoscopic endonasal transsphenoid surgery of pituitary tumors, using bipedicled nasal septal flap versus fascial closure. The study hypothesis being that bipedicled nasal septal flap is better, compared with fascial closure of skull base defect post-endoscopic endonasal transsphenoid surgery of pituitary tumors. Methods All the eligible patients were randomly divided into two groups and then randomly allocated to the surgeons. In one group, fat and fascia lata was used for closure of the skull base defect and nasal septal flap was not harvested whereas in the other, nasal septal flap was used for closure. Results There was a statistically significant difference in postoperative cerebrospinal fluid leak between the two groups. Patients who had undergone flap repair had lower incidence of postoperative cerebrospinal fluid (CSF) leak. Duration of postoperative hospital stay was also less among the group who underwent flap repair (statistically significant). Conclusion Bipedicled nasal septal flap serves an excellent cover for the skull base defect following endoscopic endonasal transsphenoidal pituitary surgery. It can prevent postoperative CSF leak even in cases where tissue glue is not used.
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Affiliation(s)
- Gokul Gopi
- All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Saurav Sarkar
- Department of ENT and HNS, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sudipta Mohakud
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Ashis Patnaik
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sumit Bansal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - C Preetam
- Department of ENT and HNS, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Rabi Narayan Sahu
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Pradipta Ku Parida
- Department of ENT and HNS, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Kühnel TS, Reichert TE. Trauma of the midface. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc06. [PMID: 26770280 PMCID: PMC4702055 DOI: 10.3205/cto000121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.
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Affiliation(s)
- Thomas S Kühnel
- Department of Otolaryngology, Head & Neck Surgery, University of Regensburg, Germany
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Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
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Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
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Gruss CL, Al Komser M, Aghi MK, Pletcher SD, Goldberg AN, McDermott M, El-Sayed IH. Risk factors for cerebrospinal leak after endoscopic skull base reconstruction with nasoseptal flap. Otolaryngol Head Neck Surg 2014; 151:516-21. [PMID: 24898075 DOI: 10.1177/0194599814536688] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The use of expanded endonasal surgery (EES) in the treatment of skull base neoplasms has increased significantly in recent years. Since 2006, the nasoseptal flap (NSF) has become the workhorse for the closure of skull base defects involving the anterior and central skull base. We hypothesized that defect site impacts the rate of cerebrospinal fluid (CSF) leak following EES. STUDY DESIGN Retrospective cohort study. SETTING/SUBJECTS/METHODS Patients who underwent skull base defect repair using a NSF at the University of California at San Francisco (UCSF) minimally invasive skull base center were retrospectively reviewed. Patient demographics, disease, and defect location and size were recorded along with the presence of a postoperative CSF leak. Data were analyzed using Fisher's exact test. RESULTS One hundred and twenty-one patients met inclusion criteria. Ten patients had a NSF failure with CSF leakage, 2 in the anterior skull base (frontal sinus, ethmoid, cribriform, planum), and 8 in the central skull base (sella, clivus) (P = .047). Dural defect size ≥2.0 cm(2) in the central skull base strongly correlated with the risk of flap failure (P = .034). CONCLUSIONS This study of endoscopic closure of skull base defects using a NSF demonstrates there is an association between both surgical site and dural defect size with NSF failure. Expanded defects of the sella and clivus have an increased risk of failure and may warrant augmented techniques.
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Affiliation(s)
- Calvin L Gruss
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, California, USA
| | - Mohammed Al Komser
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, California, USA
| | - Manish K Aghi
- Department of Neurosurgery, University of California at San Francisco, San Francisco, California, USA
| | - Steven D Pletcher
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, California, USA
| | - Andrew N Goldberg
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, California, USA
| | - Michael McDermott
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, California, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California at San Francisco, San Francisco, California, USA
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Eloy JA, Shukla PA, Choudhry OJ, Singh R, Liu JK. Challenges and surgical nuances in reconstruction of large planum sphenoidale tuberculum sellae defects after endoscopic endonasal resection of parasellar skull base tumors. Laryngoscope 2013; 123:1353-60. [PMID: 23483459 DOI: 10.1002/lary.23766] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Endoscopic endonasal transplanum transtuberculum (EETT) resection of parasellar skull base (SB) tumors often results in large SB defects with intraoperative high-flow cerebrospinal fluid (CSF) leaks. Reconstruction of these defects can be challenging because of the large defects size, communication with the suprasellar cistern, and close proximity to the optic nerves and chiasm. Recent studies have postulated that transplanum defects may be associated with increased postoperative CSF leakage. We review our experience with reconstruction of transplanum defects after EETT resection of parasellar SB tumors. Challenges encountered during these repairs and our operative nuances for successful reconstruction are discussed. METHODS A retrospective analysis was performed between March 2010 and February 2012 on patients undergoing reconstruction of transplanum defects after EETT resection of parasellar SB tumors. Repair materials, defect sizes, postoperative CSF leakage, postoperative CSF diversion, and demographic data were collected. RESULTS Nineteen patients who underwent 22 repairs with a pedicled nasoseptal flap (PNSF) were identified. The mean age was 47.6 years (range, 12-68 years). Average defect size was 5.6 cm(2) (range, 2.2-10.4 cm(2)). Three failed repairs necessitated a revision procedure. All three revisions were successfully reconstructed with the previously used PNSF. The mean follow-up period was 13.5 months (range, 1-26 months). The overall success rate was 86.4% for transplanum defects alone, as compared to 97.0% for our comprehensive PNSF experience in 99 repairs. CONCLUSION Repair of large transplanum defects after EETT resection of parasellar SB tumors presents a unique challenge. Using a PNSF along with meticulous multilayer closure may help decrease postoperative CSF leaks.
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Affiliation(s)
- Jean Anderson Eloy
- Department of Otolaryngology - Head & Neck Surgery, University of Medicine and Dentistry of New Jersey - New Jersey Medical School, Newark, New Jersey 07103, USA.
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Aguilar Cantador J, Jurado-Ramos A, Gutiérrez Jodas J, Müller Locatelli N, Cantillo Baños E, Muñoz Del Castillo F. Non-pedicled vs vascular pedicled nasal flap in repair of cerebrospinal fluid rhinorrhea. Acta Otolaryngol 2012; 132:1192-6. [PMID: 22830607 DOI: 10.3109/00016489.2012.694471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS In our study, pedicled nasal flap (NF) did not provide better results than free nasal graft (NG) for primary closure of cerebrospinal fluid (CSF) rhinorrhea. In the future, a multicenter randomized study would be needed to confirm this result. The choice of surgical technique will depend on the surgeon's experience, and the position and size of the defect. OBJECTIVES To evaluate our results in repairing CSF leaks, comparing the two techniques we used: free NG and pedicled NF. METHODS A total of 33 patients diagnosed with CSF rhinorrhea were operated on between June 2000 and May 2010; 17 were women. The mean age was 44.7 years (± 13.0). Twenty-two (66.6%) NFs of the middle and lower turbinate and septum were performed, the rest being NGs of the middle and lower turbinate only. A descriptive statistical analysis and a Kaplan-Meier survival analysis were carried out and the log-rank statistic was used to compare both techniques. RESULTS In the present study, 78% of defects were closed in all cases; NF was used in 86% (19) and NG in 63.63% (7). The mean follow-up was 71.5 (95% confidence interval (CI), 56.9-86.1) months. There were no statistically significant differences (p > 0.05).
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Affiliation(s)
- J Aguilar Cantador
- Department of Otolaryngology-Head and Neck Surgery, Reina Sofía University Hospital, School of Medicine, University of Cordoba, Spain.
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Eloy JA, Patel SK, Shukla PA, Smith ML, Choudhry OJ, Liu JK. Triple-layer reconstruction technique for large cribriform defects after endoscopic endonasal resection of anterior skull base tumors. Int Forum Allergy Rhinol 2012; 3:204-11. [DOI: 10.1002/alr.21089] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/12/2012] [Accepted: 07/17/2012] [Indexed: 11/06/2022]
Affiliation(s)
| | - Smruti K. Patel
- Department of Neurological Surgery; University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Newark; NJ
| | - Pratik A. Shukla
- Department of Otolaryngology-Head and Neck Surgery; University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Newark; NJ
| | - Mickey L. Smith
- Department of Neurological Surgery; University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Newark; NJ
| | - Osamah J. Choudhry
- Department of Neurological Surgery; University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Newark; NJ
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Kim SW, Park HW, Jeon SY, Kim DW. Versatility of the pedicled nasoseptal flap in the complicated basal skull fractures. Auris Nasus Larynx 2012; 40:334-7. [PMID: 22871375 DOI: 10.1016/j.anl.2012.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 07/16/2012] [Accepted: 07/19/2012] [Indexed: 11/29/2022]
Abstract
With the advancement of transnasal endoscopic technique, endoscopic repair of basal skull fractures has considerably substituted former external approaches. The endoscopically feasible pedicled flap, named nasoseptal flap has been extending its range of application, since it was introduced for the reconstruction of the defect after resection of skull base tumors. We introduce two patients with complicated basal skull fractures at different sites who were successfully treated by the transnasal endoscopic approach using nasoseptal flap.
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Affiliation(s)
- Sang-Wook Kim
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
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Eloy JA, Kuperan AB, Choudhry OJ, Harirchian S, Liu JK. Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks. Int Forum Allergy Rhinol 2012; 2:397-401. [PMID: 22528686 DOI: 10.1002/alr.21040] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 01/12/2012] [Accepted: 02/21/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND The advances in endoscopic skull base surgery have led to the resection of increasingly larger cranial base lesions and the creation of larger skull base defects with the potential for increased postoperative high-flow cerebrospinal fluid (CSF) leaks. These concerns led to the development of the vascularized pedicled nasoseptal flap (PNSF), which is now used as the mainstay for repair of large skull base defects in many academic centers. In this report, we review the incidence of postoperative CSF leaks in our institution in patients undergoing endoscopic skull base repair of high-flow CSF leaks with a vascularized PNSF without concurrent CSF diversion. METHODS We performed a retrospective analysis at our tertiary care medical center on patients who underwent endoscopic repair of high-flow CSF leaks using a PNSF without CSF diversion between July 2008 and August 2011. Repair materials, incidence of postoperative CSF leaks, and demographic data were collected. RESULTS Fifty-nine high-flow CSF leaks were repaired with a PNSF and other repair materials, without the use of lumbar catheter drainage. No postoperative CSF leak occurred in this cohort of patients. The overall postoperative CSF leak rate was 0%. CONCLUSION Meticulous multilayer-closure of skull base defects is critical to prevent postoperative CSF leaks. Although lumbar drainage may be useful in select scenarios, it carries inherent risks of intracranial hypotension and pneumocephalus, and may not be necessary for routine management of high-flow CSF leaks in conjunction with a robust PNSF. Further prospective randomized controlled studies may be warranted to evaluate the efficacy of postoperative lumbar drainage.
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Affiliation(s)
- Jean Anderson Eloy
- Department of Otolaryngology-Head & Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ 07103, USA.
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Eloy JA, Choudhry OJ, Friedel ME, Kuperan AB, Liu JK. Endoscopic nasoseptal flap repair of skull base defects: is addition of a dural sealant necessary? Otolaryngol Head Neck Surg 2012; 147:161-6. [PMID: 22344288 DOI: 10.1177/0194599812437530] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We compared the incidence of postoperative cerebrospinal fluid (CSF) leaks in patients undergoing endoscopic skull base repair with a pedicled nasoseptal flap (PNSF) with or without the addition of a dural sealant. STUDY DESIGN AND SETTING Retrospective analysis at a tertiary care medical center. METHODS A retrospective analysis was performed at our tertiary care medical center on patients who underwent endoscopic repair of high-flow CSF leaks using a PNSF between December 2008 and August 2011. Repair materials, incidence of postoperative CSF leaks, and demographic data were collected. RESULTS Thirty-two high-flow CSF leaks were repaired with a PNSF alone without dural sealant (group A), and 42 were repaired with a PNSF with the addition of a dural sealant (group B). In group A, there were no postoperative CSF leaks (0%), whereas in group B, there was 1 delayed postoperative CSF leak, resulting in a 2.4% leak rate. The incidence of postoperative CSF leakage was not significantly different between the 2 groups (P = .38). The overall postoperative CSF leak rate was 1.4%. CONCLUSIONS The use of dural sealants when performing endoscopic PNSF repair of high-flow CSF leaks is not supported by our data. In addition, this practice may significantly increase surgical cost. We encountered no postoperative CSF leaks in patients with high-flow CSF leaks treated with PNSF alone without dural sealants. Meticulous surgical technique and proper positioning of the PNSF seem to obviate the need for dural sealants during endoscopic skull base reconstruction of high-flow CSF leaks.
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Affiliation(s)
- Jean Anderson Eloy
- Department of Otolaryngology-Head & Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey 07103, USA.
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