Characterization of the Saddle Nose Deformity Following Endoscopic Endonasal Skull Base Surgery

Abstract

Objective The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular.

Setting/Participants This is a retrospective review of 20 adult patients with SND after EEA for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center.

Main Outcome Measures Fifteen measurements related to SND were obtained on pre- and postoperative imaging. Statistical analyses were performed to evaluate differences between pre- and postoperative anatomies.

Results The most common EEA was transsellar. Reconstruction techniques included nine free mucosal grafts alone, eight vascularized nasoseptal flaps (NSFs), one combined free mucosal graft/abdominal fat graft, and one combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection, and nasolabial angle postoperatively. Subgroup analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2 mm, p = 0.039) and increased alar base width (1.2 mm, p = 0.046) postoperatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on postoperative imaging, in contrast to those with functional adenomas who had no measurable significant changes.

Conclusion Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests.

Keywords

saddle nose deformity - endoscopic endonasal approach - nasoseptal flap - functional pituitary microadenoma - nasal deformity

Publication History

Received: 24 January 2022

Accepted: 03 March 2022

Accepted Manuscript online:
14 March 2022

Article published online:
22 April 2022

• References

• 1 Kasemsiri P, Carrau RL, Ditzel Filho LFS. et al. Advantages and limitations of endoscopic endonasal approaches to the skull base. World Neurosurg 2014; 82 (6, Suppl): S12-S21
• 2 Snyderman CH, Carrau RL, Kassam AB. et al. Endoscopic skull base surgery: principles of endonasal oncological surgery. J Surg Oncol 2008; 97 (08) 658-664
• 3 Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005; 19 (01) E8
• 4 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
• 5 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Oper Neurosurg (Hagerstown) 2007; 60 (4, suppl 2): discussion 303–304 295-303
• 6 Dehdashti AR, Stofko D, Okun J, Obourn C, Kennedy T. Endoscopic endonasal reconstruction of skull base: repair protocol. J Neurol Surg B Skull Base 2016; 77 (03) 271-278
• 7 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
• 8 Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 2012; 77 (5-6): 713-724
• 9 Morgenstern PF, Ivasyk I, Anand VK, Schwartz TH. The evolution of endoscopic skull base surgery outcomes: defining the edge of the envelope. World Neurosurg 2019; 124: 491-501
• 10 Messerer M, De Battista JC, Raverot G. et al. Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus 2011; 30 (04) E11
• 11 Gallagher MJ, Durnford AJ, Wahab SS, Nair S, Rokade A, Mathad N. Patient-reported nasal morbidity following endoscopic endonasal skull base surgery. Br J Neurosurg 2014; 28 (05) 622-625
• 12 Soudry E, Psaltis AJ, Lee KH, Vaezafshar R, Nayak JV, Hwang PH. Complications associated with the pedicled nasoseptal flap for skull base reconstruction. Laryngoscope 2015; 125 (01) 80-85
• 13 Awad AJ, Mohyeldin A, El-Sayed IH, Aghi MK. Sinonasal morbidity following endoscopic endonasal skull base surgery. Clin Neurol Neurosurg 2015; 130 (130) 162-167
• 14 Glicksman JT, Parasher AK, Brooks SG. et al. Sinonasal quality of life after endoscopic resection of malignant sinonasal and skull base tumors. Laryngoscope 2018; 128 (04) 789-793
• 15 Kimple AJ, Leight WD, Wheless SA, Zanation AM. Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate mucosal grafts. Laryngoscope 2012; 122 (09) 1920-1924
• 16 Lavigne P, Faden DL, Wang EW, Snyderman CH. Complications of nasoseptal flap reconstruction: a systematic review. J Neurol Surg B Skull Base 2018; 79 (10, suppl 4): S291-S299
• 17 Rowan NR, Wang EW, Gardner PA, Fernandez-Miranda JC, Snyderman CH. Nasal deformities following nasoseptal flap reconstruction of skull base defects. J Neurol Surg B Skull Base 2016; 77 (01) 14-18
• 18 Menick F. Nasal Reconstruction: Art and Practice. Philadelphia: Saunders Elsevier; 2009
• 19 Caicedo-Granados E, Carrau R, Snyderman CH. et al. Reverse rotation flap for reconstruction of donor site after vascular pedicled nasoseptal flap in skull base surgery. Laryngoscope 2010; 120 (08) 1550-1552
• 20 Farkas L. Anthropometry of the Head and Face. New York: Raven Press; 1994: 286-287
• 21 Atkins J. Symposium: nasal airway studies. J R Soc Med 1979; 72 (11) 846-855
• 22 Daniel RK. Rhinoplasty: septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg 2007; 119 (03) 1029-1043
• 23 Tardy Jr ME, Schwartz M, Parras G. Saddle nose deformity: autogenous graft repair. Facial Plast Surg 1989; 6 (02) 121-134
• 24 Young K, Rowe-Jones J. Current approaches to septal saddle nose reconstruction using autografts. Curr Opin Otolaryngol Head Neck Surg 2011; 19 (04) 276-282
• 25 Capone R, Papel I. The Nasal Dorsum: Management of the Upper Two-Thirds of the Nose. 2nd ed.. Baltimore: Lippincott Williams and Wilkins; 2014
• 26 Boccieri A. The crooked nose. Acta Otorhinolaryngol Ital 2013; 33 (03) 163-168
• 27 Soyka MB, Serra C, Regli L, Meier E, Holzmann D. Long-term olfactory outcome after nasoseptal flap reconstructions in midline skull base surgery. Am J Rhinol Allergy 2017; 31 (05) 334-337