1
|
Dharanipathy S, Kumar A, Agrawal D. Posterior pedicle inferior turbinate flap for recurrent cerebrospinal fluid leak following endoscopic transsphenoidal surgery. Eur Arch Otorhinolaryngol 2023; 280:4279-4283. [PMID: 37405451 DOI: 10.1007/s00405-023-08096-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Adequate reconstruction of skull base following endoscopic transsphenoidal surgery is the most crucial step in reducing postoperative morbidity and mortality. Although, the success rate of traditional nasoseptal flap is very high, specific surgical scenarios preclude its use. A variety of vascularised endonasal and tunnelled scalp flaps have been described in the literature to address such situations. Posterior pedicle inferior turbinate flap (PPITF) is one such locally available vascularised flap. METHODS Two patients with recurrent CSF leak following endoscopic transsphenoidal resection of pituitary adenoma were included. The nasoseptal flap was not available in both patients due to previous surgery. Hence, a PPITF based on the posterolateral nasal artery, a branch of sphenopalatine artery, was harvested and used for skull base reconstruction. RESULTS In both patients, CSF leak subsided in the immediate postoperative period. In one patient, sensorium improved and was subsequently discharged in stable condition. Other patient succumbed to meningitis in the postoperative period. CONCLUSIONS The PPITF is a valuable alternative to the conventional nasoseptal flap when the latter is not available and it is very important for an endoscopic skull base surgeon to be familiar with the technique of harvesting and using the PPITF.
Collapse
Affiliation(s)
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
2
|
Swing Door Compressive Fracture Technique for Turbinoplasty: Retrospective Study Based on Computed Tomography and NOSE Scale. Aesthetic Plast Surg 2022; 46:2919-2928. [PMID: 35729374 DOI: 10.1007/s00266-022-02914-7] [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: 02/08/2022] [Accepted: 04/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treatment of inferior turbinate hypertrophy is performed using different techniques in rhinoplasty. However, the reported results are not consistent. In this study, we aimed to evaluate the outcomes of Swing door compressive fracture (SDCF) technique for turbinoplasty using computed tomography (CT) and Nasal Obstruction Symptom Evaluation (NOSE) scale. METHODS This study involved retrospective analysis of 24 patients who underwent inferior turbinoplasty using Swing door compressive fracture (SDCF) technique with or without septoplasty. The angle between the inferior turbinate and lateral nasal wall, total area, inferior turbinate area and the area medial to inferior turbinate were measured preoperatively and postoperatively using coronal section CT images for objective evaluation. Moreover, the NOSE scale was used for subjective evaluation. RESULTS The angle between inferior turbinate and lateral nasal wall was decreased by 25.3% after the treatment (p <0.0001). Inevitably, postoperative total nasal airway area (area 1) did not face a statistically significant change (p = 0.6878). On the other hand, the area of inferior turbinate (area 2) decreased significantly compared to preoperative value (p = 0.0021), while the area 3, the area medial to inferior turbinate was widened 1.5 times postoperatively. The total preoperative NOSE score was moderate (39.58 ± 22.31%) and it was decreased to mild (5.83 ± 8.81%) after the treatment (p <0.0001). CONCLUSIONS The Swing door compressive fracture (SDCF) technique for turbinoplasty is an effective and straightforward modality. However, the further study involving more patients and longer follow-up period is mandatory. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
|
3
|
Huang C, Chen K, Twu C, Huang H, Hsu H. Comparison between botulinum toxin and steroid septal injection in the treatment of allergic rhinitis. Laryngoscope Investig Otolaryngol 2022; 7:12-21. [PMID: 35155778 PMCID: PMC8823147 DOI: 10.1002/lio2.726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/04/2021] [Accepted: 12/21/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To compare the effects of botulinum toxin and steroid septal injections in treating allergic rhinitis (AR) by evaluating improvements in the rhinitis control assessment test (RCAT), visual analog scale (VAS), nasal obstruction symptom evaluation (NOSE) scores, and active anterior rhinomanometry (RMM) measurements. METHODS This prospective, single-blinded cohort study was conducted at the Department of Otolaryngology, Taipei City Hospital between January 2017 and December 2018. Ninety-five patients were randomized to receive botulinum toxin, dexamethasone, or normal saline (group A, group B, and placebo, respectively). The main outcome measures were pretreatment subjective nasal symptoms (RCAT, VAS, and NOSE) and active anterior RMM measurements. All measurements were repeated during posttreatment 1, 2, and 3 months. RESULTS No significant difference was observed in pretreatment questionnaire scores and RMM values between the study and placebo groups. The mean posttreatment RCAT, VAS, and NOSE scores after 1 and 2 months significantly improved in the treatment groups compared to placebo. The VAS and NOSE at posttreatment 2 months and RCAT, VAS, and NOSE at posttreatment 3 months were significantly different comparing group A to group B. All RMM parameters showed better values in group A than in group B at 1, 2, and 3 months posttreatment, with significant differences in four parameters in posttreatment 3 months. CONCLUSIONS Botulinum toxin septal injection is a safe treatment option for AR and improves subjective nasal symptoms for 3 months. Botulinum toxin A injection tended to be more effective than steroid septal injection in terms of duration and degree.Level of Evidence: 2b, individual cohort study.
Collapse
Affiliation(s)
| | - Kuan‐Wei Chen
- Department of OtolaryngologyTaipei City HospitalTaipeiTaiwan
| | - Chih‐Wen Twu
- Department of OtolaryngologyChanghua Christian HospitalChanghuaTaiwan
- College of MedicineNational Chung Hsing UniversityTaichungTaiwan
| | - Hung‐Meng Huang
- Department of OtolaryngologyTaipei City HospitalTaipeiTaiwan
- Department of OtolaryngologySchool of Medicine, College of Medicine, Taipei Medical UniversityTaipeiTaiwan
| | - Hsin‐Chien Hsu
- Department of OtolaryngologyTaipei City HospitalTaipeiTaiwan
- General Education CenterUniversity of TaipeiTaipeiTaiwan
| |
Collapse
|
4
|
Deviated nose: Physiological and pathological changes of the nasal cavity. Arch Plast Surg 2020; 47:505-515. [PMID: 33238336 PMCID: PMC7700847 DOI: 10.5999/aps.2020.01781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/27/2020] [Indexed: 11/08/2022] Open
Abstract
Deviated nose is highly challenging in rhinoplasty since the surgeon should consider both aesthetic and functional aspects of the nose. Deviated nose correction is surgically complex, and a thorough understanding of the mechanical and physiological changes of intranasal structures, including the septum and turbinates, is necessary for functional improvement.
Collapse
|
5
|
The blood supply of the inferior nasal concha (turbinate): a cadaveric anatomical study. Anat Sci Int 2020; 96:13-19. [PMID: 32514849 DOI: 10.1007/s12565-020-00552-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
Abstract
The blood supply of the lateral nasal wall acquires a great deal of interest for many reasons especially for the treatment of clinical conditions such as epistaxis that sometimes needs surgical interventions and endoscopic sinus and skull base surgeries that requires a good choice of endonasal flaps including inferior nasal concha (commonly named as inferior turbinate by clinicians) flap to close the dural defects. Successful treatment of epistaxis and closure of such defects depends on detailed anatomical knowledge of lateral nasal wall vasculature and a vital flap with good blood supply, respectively. Because of these we aimed to study the blood supply of inferior turbinate, regarding the sources and courses of the blood vessels. Forty formalin-fixed hemisected cadaveric heads were used at Hacettepe University Anatomy Dissection Laboratory. Anatomical dissection of the inferior nasal concha and the lateral nasal wall was done by dissecting microscope. Coloring dye injection to the arteries was performed. After a detailed examination of the lateral nasal wall; the position of the sphenopalatine foramen (SPF) and the sphenopalatine artery (SPA) were identified. The posterior lateral nasal artery (PLNA) found to give middle and inferior conchal (turbinate) arteries. The average length of the inferior turbinate artery (ITA) was 9.057 ± 1.674 mm, the diameter was 1.452 ± 0.172 mm, the distance from posterior end of inferior turbinate was 7.879 ± 1.52 mm. Anastomosis in the lateral nasal wall between the ITA and the anterior ethmoidal and the lateral nasal (branch of the facial artery) arteries were established. The blood supply of inferior nasal concha is mainly provided by ITA and its anastomotic contributors. Detailed knowledge related to it, before surgical interventions, may reduce intraoperative bleeding and increase endoscopic exposure.
Collapse
|
6
|
Scott JR, Psaltis AJ, Wormald PJ. Vascular Anatomy of the Inferior Turbinate and Its Clinical Implications. Am J Rhinol Allergy 2020; 34:604-609. [PMID: 32192352 DOI: 10.1177/1945892420914185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Published reports on the vascular anatomy of the inferior turbinate (IT) are limited. Historical papers report the IT artery as a tributary off the posterior lateral nasal artery (PLNA), but this has not been our clinical experience. OBJECTIVE The purpose of this study was to examine the arterial blood supply to and the branching pattern within the IT. We discuss this is the context of IT surgery and relate it to postoperative bleeding complication rates. METHODS Endoscopic dissection was performed on 16 cadaver heads (24 sides) to determine the origin of the IT artery. Intraoperative surgical videos were analyzed in 50 patients to uncover the vascular branching pattern within the IT. A retrospective review of bleeding complications in patients undergoing IT reduction surgery was also conducted. RESULTS In 17 of 24 sides (70.8%), the IT artery arose either exclusively (54.2%) or partly (16.6%) off the descending palatine artery (DPA). As a branch off the DPA, the IT artery exited the pterygopalatine fossa through a foramen located 7.7 ± 3.0 mm from posterior edge of the IT, 8.4 ± 3.1 mm above the nasal floor and 1.6 ± 2.1 mm below the insertion of the IT bone onto the lateral nasal wall. The mean number of arteries cascading within the IT was 2.7 ± 0.5. Moreover, 112 patients underwent IT reduction surgery and 2 (1.8%) experienced postoperative epistaxis. CONCLUSION The IT artery has major contributions from the DPA. Most commonly 3 arteries branch within the IT. Knowledge of this vascular anatomy may minimize bleeding associated with IT reduction surgery.
Collapse
Affiliation(s)
- John R Scott
- Department of Otolaryngology-Head and Neck Surgery, University of Adelaide, Adelaide, Australia
| | - Alkis J Psaltis
- Department of Otolaryngology-Head and Neck Surgery, University of Adelaide, Adelaide, Australia
| | - Peter-John Wormald
- Department of Otolaryngology-Head and Neck Surgery, University of Adelaide, Adelaide, Australia
| |
Collapse
|
7
|
Chakravarthi S, Gonen L, Monroy-Sosa A, Khalili S, Kassam A. Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base. Semin Plast Surg 2017; 31:203-213. [PMID: 29075159 DOI: 10.1055/s-0037-1607274] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The success of expanded endoscopic endonasal approaches (EEAs) to the anterior skull base, sellar, and parasellar regions has been greatly aided by the advancement in reconstructive techniques. In particular, the pedicled vascularized flaps have been developed and effectively cover skull base defects of varying sizes with a significant reduction in postoperative CSF leaks. There are two aims to this review: (1) We will provide our current, simplified reconstruction algorithm. (2) We will describe, in detail, the relevant anatomy, indications/contraindications, and surgical technique, with a particular emphasis on the nasoseptal flap (NSF). The inferior turbinate flap (ITF), middle turbinate flap (MTF), pericranial flap (PCF), and temporoparietal fascial flap (TPFF) will also be described. The NSF should be the primary option for reconstruction of majority of skull base defects following endonasal endoscopic surgery. In general, for the planum, cribriform, and upper two-thirds of the clivus, the NSF is ideal. For the lower-third of the clivus, the NSF may not be adequate and may require additional reconstructive options. Although limited in reach or more technically challenging, these reconstructive flaps should still be considered and kept in the surgical algorithm.
Collapse
Affiliation(s)
- Srikant Chakravarthi
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Lior Gonen
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Alejandro Monroy-Sosa
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Sammy Khalili
- Department of Otorhinolaryngology, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Amin Kassam
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| |
Collapse
|
8
|
Abstract
BACKGROUND To resolve nasal obstruction in rhinoplasty, inferior turbinate outfracture is performed widely alone or combined with other procedures. There are conflicting reports on the effect of inferior turbinate outfracture. This study evaluated the persistence of morphologic changes after inferior turbinate outfracture. METHODS This retrospective study enrolled 55 patients who underwent inferior turbinate outfracture without septal surgery to approach the sphenoid sinus for brain tumor removal. Coronal paranasal sinus computed tomographic images obtained preoperatively and 6 months postoperatively were compared. The authors measured the shortest distance from the median line to the medial border of the conchal bone and the shortest distance from the medial border of the conchal bone to the lateral nasal line. The authors also gauged the projection angle of the conchal bone and constitutional thickness of the inferior turbinate. RESULTS After inferior turbinate outfracture, the shortest distance from the median line to the medial border of the conchal bone increased, and shortest distance from the medial border of the conchal bone to the lateral nasal line decreased. The projection angle decreased significantly by 6 months postoperatively. After outfracture, the thickness of the medial mucosa had increased significantly, wheras the thickness of the conchal bone had decreased significantly (p < 0.05). CONCLUSIONS The effect of inferior turbinate outfracture is preserved for at least 6 months. Moreover, compensatory hypertrophy of the medial mucosa develops in the inferior turbinate after outfracture. Therefore, outfracture with medial submucosal volume reduction would be recommended as the best procedure for treating inferior turbinate hypertrophy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
9
|
Wu P, Li Z, Liu C, Ouyang J, Zhong S. The posterior pedicled inferior turbinate–nasoseptal flap: a potential combined flap for skull base reconstruction. Surg Radiol Anat 2015; 38:187-94. [DOI: 10.1007/s00276-015-1516-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 06/29/2015] [Indexed: 12/01/2022]
|
10
|
Choby GW, Pinheiro-Neto CD, de Almeida JR, Ruiz-Valdepeñas EC, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Extended inferior turbinate flap for endoscopic reconstruction of skull base defects. J Neurol Surg B Skull Base 2014; 75:225-30. [PMID: 25093144 DOI: 10.1055/s-0033-1358791] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 09/09/2013] [Indexed: 10/25/2022] Open
Abstract
Objective When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design Cadaveric anatomical study. Participants Cadaveric specimens. Main Outcome Measures Flap size, arc of rotation, and reconstructive applications were assessed. Results The average width of the flap was 5.46 ± 0.58 cm (7.32 ± 0.59 cm with septal mucosa). The average length of the flap was 5.01 ± 0.58 cm (5.28 ± 0.37 cm with septal mucosa). The average surface area of the flap was ∼ 27.26 ± 3.65 cm(2) (40.53 ± 6.45 cm(2) with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable.
Collapse
Affiliation(s)
- Garret W Choby
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carlos D Pinheiro-Neto
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - John R de Almeida
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | | | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States ; Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
11
|
Morphological consequences of lateral outfracture of the inferior turbinate. The Journal of Laryngology & Otology 2013; 127:323-8. [PMID: 23363488 DOI: 10.1017/s0022215112003234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We report three cases of lateral outfracture of the inferior turbinate, which demonstrate a range of changes in the size, position and shape of the inferior turbinate. METHOD During a study of the validity of computer modelling of nasal airflow, computed tomography scans of the noses of patients who had undergone lateral outfracture of the inferior turbinate were collected. The pre-operative scan was compared with the post-operative scan six weeks later. RESULTS In one patient, there was only a small lateral displacement of the inferior turbinate. In the other two cases, appreciable reduction in the volume of one inferior turbinate was noted, in addition to minor changes in the shape. CONCLUSION Lateral outfracture of the inferior turbinate produces varied and inconsistent changes in morphology which may affect the shape, size and position of the turbinate.
Collapse
|
12
|
Amit M, Cohen J, Koren I, Gil Z. Cadaveric study for skull base reconstruction using anteriorly based inferior turbinate flap. Laryngoscope 2013; 123:2940-4. [PMID: 23804533 DOI: 10.1002/lary.24186] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 03/27/2013] [Accepted: 04/12/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To demonstrate the feasibility of an anteriorly pedicled inferior turbinate flap (AITF) as a method for endoscopic reconstruction of anterior skull base defects in the absence of a nasal septal flap. STUDY DESIGN Cadaveric feasibility study. SETTING University-affiliated tertiary medical center. MATERIALS AND PATIENTS A cadaveric model was used to investigate the feasibility of harvesting and skull base reconstruction with an AITF. The size and extent of coverage of the flap were investigated. Subsequently, defects resulting from an endoscopic resection of various anterior skull base pathologies were reconstructed with an AITF in patients. RESULTS In the cadaveric model (n = 11), the mean length, width, and area of the AITFs were 4.76 ± 0.52 cm, 1.8 ± 0.34 cm, and 4.31 ± 0.87 cm(2), respectively. The flap provided a mean of 111 ± 12% (range 95%-133%) coverage of the anterior skull base from the posterior table of the frontal sinus to the sella. Following that experience, ten patients were successfully reconstructed with AITFs, and there were no postoperative cerebrospinal fluid (CSF) leaks or occurrence of meningitis. CONCLUSION The results of this study demonstrate the feasibility of AITFs for the reconstruction of anterior skull base defects in the absence of alternative vascularized flaps.
Collapse
Affiliation(s)
- Moran Amit
- Department of Otolaryngology Head and Neck Surgery, Rambam Medical Center, Haifa, Israel
| | | | | | | |
Collapse
|
13
|
Yip J, Macdonald KI, Lee J, Witterick IJ, Zadeh G, Gentili F, Vescan AD. The inferior turbinate flap in skull base reconstruction. J Otolaryngol Head Neck Surg 2013; 42:6. [PMID: 23663897 PMCID: PMC3646555 DOI: 10.1186/1916-0216-42-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 12/25/2012] [Indexed: 12/02/2022] Open
Abstract
Background As the indications for expanded endonasal approaches continue to evolve, alternative reconstructive techniques are needed to address increasingly complex surgical skull base defects. In the absence of the nasoseptal flap, we describe our experience with the posterior pedicle inferior turbinate flap (PPITF) in skull base reconstruction. Design Case series. Setting Academic tertiary care centre. Methods Patients who underwent reconstruction of the skull base with the PPITF were identified. Medical records were reviewed for demographic, presentation, treatment, follow-up, surgical and outcomes data. Main outcome measures Flap survival, adequacy of seal, and complications. Results Two patients with residual/recurrent pituitary adenomas met the inclusion criteria. The nasoseptal flap was unavailable in each case due to a prior septectomy. Salvage of the original nasoseptal flap was not possible, as it did not provide adequate coverage of the resultant defect due to contraction from healing. All PPITFs healed uneventfully and covered the entire defect. No complications were observed in the early post-operative period. Endoscopic techniques and limitations of the PPITF are also discussed. Conclusions Our clinical experience supports the PPITF to be a viable alternative for reconstruction of the skull base in the absence of the nasoseptal flap.
Collapse
Affiliation(s)
- Jonathan Yip
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.
| | | | | | | | | | | | | |
Collapse
|
14
|
Berger G, Eviatar E, Kogan T, Landsberg R. The normal uncinate process: histology and clinical relevance. Eur Arch Otorhinolaryngol 2012; 270:959-64. [PMID: 22948861 DOI: 10.1007/s00405-012-2169-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 08/16/2012] [Indexed: 11/30/2022]
Abstract
In this three-center, prospective, non-randomized, controlled trial, we performed a qualitative and quantitative histological and morphometric assessment of the normal uncinate process (UP). The soft tissue and bony elements of the normal UP of 16 adults were investigated and compared with 28 age- and gender-matched archival reference-group samples of neighboring structures of the inferior and middle turbinates. A series of measurements were taken and included the thickness of the mucosal layers and bone, epithelial height, basement membrane thickness, number of lamina propria inflammatory cells, and the area fraction (AF) of the epithelium, connective tissue, glands, veins and arteries. The data showed that the medial and lateral mucosal layers are built of loose connective tissue and harbor various inflammatory cell population, abundant glands, and thin-walled small-caliber venules. In-between, there is a thin lamellar compact bone (≤ 80 μm) or a significantly thicker cancellous bone (110-400 μm; P < 0.001). Both mucosal layers are similar in thickness, epithelial height, basement membrane thickness, and AF of soft-tissue constituents. A comparison with the lateral aspect of the inferior and middle turbinates showed that the AF of the connective tissue, total submucosal glands, submucosal serous and mucous glands, and veins of the lateral mucosa are significantly different (all P < 0.001). This diversity may point to different physiological roles for the UP and the inferior and middle turbinates. The UP rich glandular network, which is probably responsible for drainage and ventilation of the maxillary sinus into the ethmoid infundibulum laterally and the frontal sinus into the middle meatus medially, supports the argument that it is preferable, particularly for the less complicated cases, to keep the normal physiology of the ethmoid infundibulum and use bone- and mucosa-sparing techniques for the management of refractory chronic sinus disease.
Collapse
Affiliation(s)
- Gilead Berger
- Ear, Nose, and Throat Histopathological Research Laboratory of Department of Otolaryngology-Head and Neck Surgery, Meir Medical Center, 59 Tchernichovsky St., Kfar Saba, 44281, Israel.
| | | | | | | |
Collapse
|
15
|
Rivera-Serrano CM, Bassagaisteguy LH, Hadad G, Carrau RL, Kelly D, Prevedello DM, Fernandez-Miranda J, Kassam AB. Posterior pedicle lateral nasal wall flap: new reconstructive technique for large defects of the skull base. Am J Rhinol Allergy 2012; 25:e212-6. [PMID: 22185727 DOI: 10.2500/ajra.2011.25.3693] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Indications for expanded endoscopic approaches continue to grow, resulting in larger and more complex skull base defects. Reconstructive developments, however, have lagged our extirpative capabilities. As the complexity of clinical scenarios continues to escalate, challenging our current reconstructive strategies, we are compelled to develop alternative techniques to prevent cerebrospinal fluid leaks and protect neurovascular structures. In this article we show the anatomic basis for a new posterior pedicled flap from the lateral wall of the nose (Carrau-Hadad [C-H] flap) for the reconstruction of median skull base defects and present our early clinical experience. METHODS Using a cadaveric model, we designed a posterior pedicle flap comprising the nasal inferolateral wall mucoperiosteum. We applied this information clinically, to reconstruct transmural skull base defects. RESULTS In our cadaveric model, we harvested and transposed C-H flaps into various defects of the planum sphenoidale, sella turcica, clivus, and nasopharynx. Then, we used the C-H flap in four patients, successfully reconstructing their clival (n = 3) and sellar (n = 1) surgical defects. All patients healed uneventfully. CONCLUSION Our anatomic study and early clinical experience support the use of the posterior pedicle lateral nasal wall flap to reconstruct large cranial base defects resulting from endoscopic skull base surgery in properly selected patients.
Collapse
Affiliation(s)
- Carlos M Rivera-Serrano
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Gil Z, Margalit N. Anteriorly Based Inferior Turbinate Flap for Endoscopic Skull Base Reconstruction. Otolaryngol Head Neck Surg 2012; 146:842-7. [DOI: 10.1177/0194599811434516] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. In the absence of the nasal septal flap, there is limited ability to reconstruct the anterior skull base because of the paucity of alternative intranasal vascularized flaps. In this article, the authors describe the anteriorly pedicled inferior turbinate flap (AITF) as a method for endoscopic reconstruction of anterior skull base defects. Study Design. A case series with chart review of the demographic, clinical, surgical, and early follow-up data of patients who underwent endoscopic reconstruction of skull base defects by the AITF. Setting. An academic cancer center. Methods. The nature of the arterial blood supply of the inferior turbinate from the anterior ethmoidal artery was exploited to design an anteriorly pedicled flap. Flap survival, adequacy of the seal, and rate of complications were assessed. Results. Seven patients were suitable to undergo anterior skull base reconstruction using the AITF with or without combinations with other flaps. Each had a high-flow intraoperative cerebrospinal fluid (CSF) leak. The reconstruction achieved covering of the anterior skull base, including the frontal sinus and cribriform plate, with no postoperative CSF leaks or any other complications. Conclusion. The AITF is well tolerated and is associated with good outcomes. Its length and angle of rotation allow reconstruction of skull base defects in the posterior frontal sinus wall and cribriform plate, especially when traditional reconstruction techniques are not possible.
Collapse
Affiliation(s)
- Ziv Gil
- The Head and Neck Surgery Unit, Departments of Otolaryngology–Head and Neck Surgery and Neurosurgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Israel Tel Aviv, Israel
| | - Nevo Margalit
- The Head and Neck Surgery Unit, Departments of Otolaryngology–Head and Neck Surgery and Neurosurgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Israel Tel Aviv, Israel
| |
Collapse
|
17
|
Zanation AM, Thorp BD, Parmar P, Harvey RJ. Reconstructive Options for Endoscopic Skull Base Surgery. Otolaryngol Clin North Am 2011; 44:1201-22. [DOI: 10.1016/j.otc.2011.06.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
18
|
Hadad G, Rivera-Serrano CM, Bassagaisteguy LH, Carrau RL, Fernandez-Miranda J, Prevedello DM, Kassam AB. Anterior pedicle lateral nasal wall flap: A novel technique for the reconstruction of anterior skull base defects. Laryngoscope 2011; 121:1606-10. [DOI: 10.1002/lary.21889] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
19
|
Orhan M, Midilli R, Gode S, Saylam CY, Karci B. Blood supply of the inferior turbinate and its clinical applications. Clin Anat 2010; 23:770-6. [DOI: 10.1002/ca.21019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 05/16/2010] [Accepted: 05/19/2010] [Indexed: 11/07/2022]
|
20
|
Bhatki AM, Pant H, Snyderman CH, Carrau RL, Kassam AB, Prevedello DM, Gardner P. Reconstruction of the cranial base after endonasal skull base surgery: Local tissue flaps. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.otot.2009.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
21
|
Fortes FSG, Carrau RL, Snyderman CH, Prevedello D, Vescan A, Mintz A, Gardner P, Kassam AB. The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope 2007; 117:1329-32. [PMID: 17597634 DOI: 10.1097/mlg.0b013e318062111f] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Expanded endonasal approaches (EEA) for the resection of lesions of the anterior and ventral skull base can create large defects with a significant risk of postoperative cerebrospinal fluid (CSF) leaks or exposure of the internal carotid artery. In these cases, a reconstruction using a vascularized flap facilitates rapid and complete healing of the defect. The Hadad-Bassagasteguy flap (HBF), a posterior pedicle nasoseptal flap, is our preferred reconstructive option; however, a prior posterior septectomy or prior wide sphenoidotomies preclude its use. We have developed two additional pedicled flaps to reconstruct these selected patients: the transpterygoid temporoparietal fascia flap, which is suitable for large defects, and the posterior pedicle inferior turbinate flap (PPITF), the subject of this paper. METHODS We developed a flap comprising the inferior turbinate mucoperiosteum pedicled on the inferior turbinate artery, a terminal branch of the posterior lateral nasal artery, which arises from the sphenopalatine artery. We retrospectively reviewed the clinical data of four patients who underwent a skull base reconstruction using a PPITF. RESULTS Four patients underwent a reconstruction with the PPITF after undergoing an EEA that produced a skull base defect associated with a CSF fistula (n = 2), an exposed internal carotid artery (n = 1), or a basilar aneurysm clip (n = 1). All patients had undergone posterior septectomies as part of previous EEAs. All flaps healed uneventfully and covered the entire defect. CONCLUSION The PPITF is a viable reconstructive option for patients with skull base defects of a limited size defect and in whom the HBF is not available.
Collapse
Affiliation(s)
- Felipe S G Fortes
- Department of Otolaryngology and Head and Neck Surgery, Minimally Invasive endoNeurosurgery Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | | | |
Collapse
|