Torn Nasoseptal Flap, Does Repair of the Perforation Affect Postoperative Cerebrospinal Fluid Leak?

Colin Huntley; Gurston G. Nyquist; Alfred M. Iloreta; Marc Otten; Hermes Garcia; Chris Farrell; Marc R. Rosen; James J. Evans

doi:10.1055/s-0035-1546499

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

Torn Nasoseptal Flap, Does Repair of the Perforation Affect Postoperative Cerebrospinal Fluid Leak?

Colin Huntley ¹, Gurston G. Nyquist ¹, Alfred M. Iloreta ¹, Marc Otten ¹, Hermes Garcia ¹, Chris Farrell ¹, Marc R. Rosen ¹, James J. Evans ¹

¹Thomas Jefferson University, United States

Abstract

Background: The nasoseptal flap (NSF) has been shown to be a valuable tool for the prevention of cerebrospinal fluid (CSF) leak in the reconstruction of skull base defects. During harvest of the NSF, a mucosal tear can occur, often along a large septal spur or deviated maxillary crest. We evaluated our population of patients whose NSF was torn during harvest and compared the rate of postoperative CSF leaks between those tears left unrepaired and those repaired with suture.

Methods: We reviewed our database of patients undergoing skull base surgery and identified patients who had an NSF reconstruction, septoplasty, and/or spur on preoperative CT scan imaging. The video was analyzed to identify a tear in the NSF and if that tear was repaired. Tears were typically repaired with 4–0 chromic suture. Patient records were reviewed to determine if a postoperative CSF leak occurred. The group of patients whose torn NSF was repaired with suture was compared with the group of patients whose torn NSF was not repaired. Lumbar drains were used intermittently, only in cases of encephalocele repair, during the evaluation of suspected intracranial hypertension.

Results: We evaluated video of 22 patients who underwent a skull base resection and were reconstructed with an NSF. Of these 22 cases, 12 small mucosal tears occurred during the harvest of the NSF flap. Four of the tears were repaired with chromic suture before flap placement at the cranial base defect. Zero of the four patients in the group whose perforated NSF was repaired with suture before placement at the cranial base defect had a postoperative CSF leak and zero of the eight patients in the group whose perforated NSF was left unrepaired before placement had a postoperative CSF leak.

Conclusion: Mucosal tears in the NSF likely do not require primary repair and do not increase the risk of postoperative CSF leak rates. This likely underscores the importance of a solid primary repair of the dura in addition to the NSF as part of the multilayer reconstruction of complicated skull base defects.