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Endoscopic Reconstruction of Skull Base Defects with the Nasal Septal Flap
29 October 2008 (online)
Objectives: Endoscopic technology is allowing larger resections of the anterior and middle skull base with resultant dural defects. A pedicled nasal septal flap (NSF) based on the posterior nasal septal artery has recently been developed for closure of these defects. We describe our initial experience with the NSF for vascularized coverage of skull base defects. Design: Retrospective review. Setting: Tertiary care skull base center. Participants: Patients undergoing endoscopic harvest of vascularized pedicled flap for skull base reconstruction. Results: Twenty-eight patients had 32 NSFs raised over 14 months for benign (7) or malignant (21) lesions. Surgical defects (mean, 4.95 cm2) were intracranial (25) and intradural (20, average defect 1.86 cm2) in the anterior (10) and central skull base (6), infratemporal fossa (4), orbit (1), or a combination of sites (9). There were no cases of meningitis or cerebrospinal fluid leak (median follow-up, 8.3 months). Two NSFs were injured intraoperatively and two necrosed postoperatively, both in patients with a prior history of radiation to the nasopharynx (p = 0.013). Conclusions: Prior radiation is a risk factor for necrosis. The NSF is easily harvested endonasally, reliably covers a range of skull base defects, and should be considered the first line closure after expanded endonasal skull base resections.
Nasal septal flap - skull base - endoscopic approach
1 El-Sayed I H, Saleh H.
Neurosurgical Complications in Otolaryngology MWM. In: Eisele DW, Smith RV Complications of Otolaryngology—Head and Neck Surgery. 2nd ed. Philadelphia, PA; Elsevier 2008: 110-132
- 2 Hegazy H M, Carrau R L, Snyderman C H, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000; 110 1166-1172
- 3 Basu D, Haughey B H, Hartman J M. Determinants of success in endoscopic cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg. 2006; 135 769-773
- 4 Gil Z, Abergel A, Leider-Trejo L et al.. A comprehensive algorithm for anterior skull base reconstruction after oncological resections. Skull Base. 2007; 17 25-37
- 5 Fliss D M, Gil Z, Spektor S et al.. Skull base reconstruction after anterior subcranial tumor resection. Neurosurg Focus. 2002; 12 e10
- 6 Kassam A B, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. 2005; 19 E6
- 7 Kassam A, Snyderman C H, Mintz A, Gardner P, Carrau R L. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005; 19 E3
- 8 Kassam A, Snyderman C H, Mintz A, Gardner P, Carrau R L. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus. 2005; 19 E4
- 9 Leong J L, Citardi M J, Batra P S. Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms. Am J Rhinol. 2006; 20 476-482
- 10 Snyderman C H, Kassam A B, Carrau R, Mintz A. Endoscopic reconstruction of cranial base defects following endonasal skull base surgery. Skull Base. 2007; 17 73-78
- 11 Sade B, Mohr G, Frenkiel S. Management of intra-operative cerebrospinal fluid leak in transnasal transsphenoidal pituitary microsurgery: use of post-operative lumbar drain and sellar reconstruction without fat packing. Acta Neurochir (Wien). 2006; 148 13-18 discussion 18-19
- 12 Kassam A, Carrau R L, Snyderman C H, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus. 2005; 19 E8
13 Goldberg A N, Lanza D C.
Extracranial closure of cerebrospinal fluid rhinorrhea using a mucoperiosteal flap. 2nd ed. In: Baily BJ, Calhoun KH, Friedman N, Newlands SD, Vrabec JT Atlas of Head and Neck Surgery—Otolaryngology. 2nd ed. Philadelphia, PA; Lippincott Williams and Wilkins 2001: 890-893
- 14 Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope. 2003; 113 1425-1428
- 15 Berinstein T H, Bernstein P. The turbinate flap for reconstruction of nasal septal mucosal defects. Laryngoscope. 1996; 106 1047-1048
- 16 Schultz-Coulon H J. Experiences with the bridge-flap technique for the repair of large nasal septal perforations. Rhinology. 1994; 32 25-33
- 17 El-Banhawy O A, Halaka A N, El-Dien A E, Ayad H. Sellar floor reconstruction with nasal turbinate tissue after endoscopic endonasal transsphenoidal surgery for pituitary adenomas. Minim Invasive Neurosurg. 2003; 46 289-292
- 18 Hadad G, Bassagasteguy L, Carrau R L et al.. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006; 116 1882-1886
- 19 Fortes F S, Carrau R L, Snyderman C H et al.. The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope. 2007; 117 1329-1332
- 20 Cantu G, Solero C L, Pizzi N, Nardo L, Mattavelli F. Skull base reconstruction after anterior craniofacial resection. J Craniomaxillofac Surg. 1999; 27 228-234
- 21 Deschler D G, Gutin P H, Mamelak A N, McDermott M W, Kaplan M J. Complications of anterior skull base surgery. Skull Base Surg. 1996; 6 113-118
- 22 Snyderman C, Kassam A, Carrau R et al.. Acquisition of surgical skills for endonasal skull base surgery: a training program. Laryngoscope. 2007; 117 699-705
Ivan El-SayedM.D. F.A.C.S.
Otolaryngic Division Minimally Invasive Skull Base Surgery, Department of Otolaryngology, University of California at San Francisco
400 Parnassus Ave., San Francisco, CA 94143-0342