Complex Skull Base Reconstruction in Kadish D Esthesioneuroblastoma: Case Report

Introduction: Advanced Kadish staging for esthesioneuroblastoma correlates with greater complications, recurrence rates, and mortality. These advanced stage malignancies require more extensive resections and aggressive adjuvant therapy to obtain good disease-free control. This aggressive approach may encourage complications such as cerebrospinal fluid (CSF) leak, wound complications, and osteomyelitis. We describe the case of a patient with Kadish D esthesioneuroblastoma who underwent multiple surgeries for infectious, neurologic, and wound complications.

Case Presentation: We present the case of a 61-year-old male who presented with nasal congestion and a large left-sided esthesioneuroblastoma, with extension into the paranasal sinuses, orbit, frontal lobe, leptomeninges, and parapharyngeal nodes (Fig. 1).

He underwent margin-free endoscopic-assisted craniofacial resection for his Kadish D stage disease, with adjuvant craniofacial and cervical radiotherapy and concomitant chemotherapy with good results (Fig. 2).

He then returned with breakdown of his skull base reconstruction and subsequent frontal infections, and ultimately received 10 surgical procedures with three surgeries for infection-related issues including craniectomies, cranioplasties, and abscess evacuation. He also had four separate surgeries performed for skull base reconstruction and cerebrospinal fluid leak (Figs. 3–7), repaired with the use of vascularized pericranium, fascia lata, pedicled myofascial flaps, AlloDerm, fibrin sealants, and CSF diversion with lumbar drains and peritoneal shunts.

Discussion: Extensive, high Kadish stage tumors necessitate radical surgical resection, radiation, and chemotherapy. This can lead to complications including CSF leak and infections requiring repeat surgeries and reconstructions. Vascularized grafts have been shown to be more robust in the setting of adjuvant therapy, but these too can fail. Nevertheless, multiple allografts, synthetics, free tissues, and pedicled flaps, with adjunctive sealants and CSF diversion can be used for reconstruction, even sequentially after multiple failures. Ultimately, there are several options available to surgeons, and although precautions should be taken whenever possible, risk of wound breakdown, leak, or infection should not preclude radical surgical resection and aggressive adjuvant therapies in the treatment of esthesioneuroblastoma.

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