Lateral nasal wall extension of the nasoseptal flap for skull‐base and medial orbital wall defects

Background Anterior and posterior ethmoid arteries supply the paranasal sinuses, septum, and lateral nasal wall. Precise identification of these arteries is important during anterior skull base procedures, endoscopic sinus surgery, and ligation of ethmoid arteries for epistaxis refractory to standard treatment. There is controversy in the literature regarding the prevalence of supernumerary ethmoid arteries. Objective This study examined the prevalence of supernumerary ethmoid arteries by using direct visualization after transorbital endoscopic dissection. Methods Nineteen cadaveric specimens were evaluated by using a superior lid crease (blepharoplasty) incision and an endoscopic approach to the medial orbital wall. Ethmoid arteries were identified as they pierced the lamina papyracea coplanar with the skull base and optic nerve. The distances from the anterior lacrimal crest to the ethmoid arteries and optic nerve were measured with a surgical ruler under endoscopic guidance. Results Thirty-eight cadaveric orbits were measured. Overall, there were three or more ethmoid arteries (including anterior and posterior arteries) in 58% of orbits, with 8% of the total sample that contained four or more ethmoid arteries. The average number of ethmoid arteries was 2.7. Bilateral supernumerary ethmoid arteries were noted in 42% of the specimens. The distance between the anterior lacrimal crest and the anterior ethmoid, posterior ethmoid, and optic nerve averaged 20, 35, and 41 mm, respectively. The average distance to the supernumerary or middle ethmoid artery was 29 mm. Conclusion This study found supernumerary ethmoid arteries in 58% of cadaveric specimens, a prevalence much higher than previously reported. Recognition of these additional vessels may improve safety during endoscopic sinus surgery and skull base surgery, and may permit more effective ligation for refractory epistaxis originating from the ethmoid system.

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Vascularized Nasoseptal Flap for Medial Orbital Wall Reconstruction

Journal of Craniofacial Surgery ◽

10.1097/scs.0000000000002836 ◽

2016 ◽

Vol 27 (6) ◽

pp. 1532-1534

Author(s):

Mazda K. Turel ◽

Christopher J. Chin ◽

Allan D. Vescan ◽

Fred Gentili

Keyword(s):

Nasoseptal Flap ◽

Orbital Wall ◽

Medial Orbital Wall

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Diagnostic accuracy of computed tomography and magnetic resonance imaging compared to surgical exploration for anterior skull base and medial orbital wall infiltration in advanced sinonasal tumors

Head & Neck ◽

10.1002/hed.26129 ◽

2020 ◽

Vol 42 (8) ◽

pp. 2002-2012

Author(s):

Christian M. Meerwein ◽

Shila Pazahr ◽

Michael B. Soyka ◽

Martin W. Hüllner ◽

David Holzmann

Keyword(s):

Magnetic Resonance Imaging ◽

Computed Tomography ◽

Magnetic Resonance ◽

Diagnostic Accuracy ◽

Skull Base ◽

Anterior Skull Base ◽

Resonance Imaging ◽

Surgical Exploration ◽

Orbital Wall ◽

Medial Orbital Wall

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Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects

Journal of Neurosurgery ◽

10.3171/2018.10.jns181556 ◽

2020 ◽

Vol 132 (2) ◽

pp. 371-379 ◽

Cited By ~ 4

Author(s):

Ju Hyung Moon ◽

Eui Hyun Kim ◽

Sun Ho Kim

Keyword(s):

Skull Base ◽

Inferior Turbinate ◽

Lateral Nasal Wall ◽

Dural Defect ◽

Nasoseptal Flap ◽

Endonasal Surgery ◽

Csf Rhinorrhea ◽

Nasal Floor ◽

Dural Defects ◽

Skull Base Defects

OBJECTIVEEndonasal surgery of the skull base requires watertight reconstruction of the skull base that can seal the dural defect to prevent postoperative CSF rhinorrhea and consequent intracranial complications. Although the incidence of CSF leakage has decreased significantly since the introduction in 2006 of the vascularized nasoseptal flap (the Hadad-Bassagasteguy flap), reconstruction of extensive skull base dural defects remains challenging. The authors describe a new, modified vascularized nasoseptal flap for reconstruction of extensive skull base dural defects.METHODSA retrospective review was conducted on 39 cases from 2010 to 2017 that involved reconstruction of the skull base with an endonasal vascularized flap. Extended nasoseptal flaps were generated by adding the nasal floor and inferior meatus mucosa, inferior turbinate mucosa, or entire lateral nasal wall mucosa. The authors specifically highlight the surgical techniques for flap design and harvesting of these various modifications of the vascularized nasoseptal flap.RESULTSThirty-nine endonasal vascularized flaps were used to reconstruct skull base defects in 37 patients with nonsurgical or postoperative CSF rhinorrhea. Of the 39 procedures, extended nasoseptal flaps were used in 5 cases (13%). These included 2 extended nasoseptal flaps including the inferior turbinate mucosa and 3 extended nasoseptal flaps including the entire lateral nasal wall mucosa. These 5 extended nasoseptal flaps were used in patients who had nonsurgical CSF rhinorrhea due to extensive skull base destruction by invasive pituitary tumors. All flaps healed completely and sealed off the CSF leaks. Olfactory function slightly decreased in the 3 patients with extended nasoseptal flaps including the entire lateral nasal wall mucosa. One patient experienced nasolacrimal duct obstruction, which was treated by dacryocystorhinostomy. The authors encountered no wound complication in this series, while crusting at the donor site required daily nasal toilette and frequent debridement until the completion of mucosalization, which usually takes 8 to 12 weeks after surgery.CONCLUSIONSExtended nasoseptal flaps are a reliable and versatile option that can be used to reconstruct extensive skull base dural defects resulting from destruction by large invasive tumors or complex endoscopic endonasal surgery. An extended nasoseptal flap that includes the entire lateral nasal wall mucosa (360° flap) is the largest endonasal vascularized flap reported to date and may be an alternative for the reconstruction of extensive skull base defects while avoiding the need for additional external approaches.

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Safety of Ethmoid Sinus Drug-Eluting Catheter Insertion

Otolaryngology ◽

10.1016/j.otohns.2008.05.544 ◽

2008 ◽

Vol 139 (2_suppl) ◽

pp. P108-P108

Author(s):

Christopher T Melroy ◽

Frederick A Kuhn

Keyword(s):

Skull Base ◽

Topical Therapy ◽

Topical Drug Delivery ◽

Lamina Papyracea ◽

Post Procedure ◽

Orbital Wall ◽

The Face ◽

Drug Eluting ◽

Medial Orbital Wall ◽

Ethmoid Sinuses

Problem The objective is to develop an instrument which allows a drug-eluting catheter to be safely and reproducibly inserted into the ethmoid sinuses. Methods A trochar-based insertion device was designed to allow delivery of a drug-eluting catheter into the anterior and posterior ethmoid sinuses. It was inserted into 12 cadaveric ethmoid sinuses under endoscopic and fluoroscopic guidance. CT scans were performed pre-, intra-, and post-procedure. The device's position was analyzed and the proximity to the skull base, lamina papyracea, and ethmoid face was measured. The specimens were then dissected and evaluated for skull base, sphenoid face, or lamina papyracea injury. Results The drug eluting catheter system was successfully inserted into the ethmoid sinuses of all 12 cadaver sides without injury to either the medial orbital wall or the skull base as confirmed by post-procedure CT scan and dissection. The final position of the distal tip of the stent averaged 8.1mm (RMS = 3.3) from the skull base, 5.6mm (RMS=3.5) from the sphenoid face, and 5.0mm (RMS=3.5) from the lamina papyracea; the proximal tip was at the face of the ethmoid bulla and 17.1mm (RMS=3.5) below the skull base. Conclusion This study demonstrates that a trochar-based instrument can safely and reproducibly introduce a drug-eluting catheter into the ethmoid sinuses without skull base or lamina papyracea injury. This device may allow safe topical drug delivery into the ethmoid sinuses and provide chronic ethmoid sinusitis patients an alternative to ethmoidectomy. Significance The primary surgical therapy for chronic ethmoid sinusitis is ethmoidectomy; topical therapy has been widely used in the management of chronic ethmoid sinusitis only after ethmoidectomy. This study shows a drug-eluting catheter can be safely and reliably inserted into virgin ethmoid sinuses in order to allow the topical elution of medications into the ethmoids without ethmoidectomy. Support Acclarent supplied cadaveric specimens.

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Radiological Classification of Anterior Skull Base Anatomy Prior to Performing Medial Orbital Wall Decompression

Orbit ◽

10.1080/01676830600674627 ◽

2006 ◽

Vol 25 (2) ◽

pp. 93-96 ◽

Cited By ~ 15

Author(s):

V. Gauba ◽

G. M. Saleh ◽

G. Dua ◽

S. Agarwal ◽

S. Ell ◽

...

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Orbital Wall ◽

Radiological Classification ◽

Skull Base Anatomy ◽

Medial Orbital Wall

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Resources: Internet Resources for the Independent Medical Evaluator – 2007

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2007.julaug02 ◽

2007 ◽

Vol 12 (4) ◽

pp. 4-7

Author(s):

Christopher R. Brigham ◽

Jenny Walker

Keyword(s):

Head Trauma ◽

Clonic Seizure ◽

Acute Subdural Hematoma ◽

Orbital Fracture ◽

Orbital Wall ◽

First Occurrence ◽

One Year ◽

The One ◽

Neurological Injuries ◽

Medial Orbital Wall

Abstract Rating patients with head trauma and multiple neurological injuries can be challenging. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 13.2, Criteria for Rating Impairment Due to Central Nervous System Disorders, outlines the process to rate impairment due to head trauma. This article summarizes the case of a 57-year-old male security guard who presents with headache, decreased sensation on the left cheek, loss of sense of smell, and problems with memory, among other symptoms. One year ago the patient was assaulted while on the job: his Glasgow Coma Score was 14; he had left periorbital ecchymosis and a 2.5 cm laceration over the left eyelid; a small right temporoparietal acute subdural hematoma; left inferior and medial orbital wall fractures; and, four hours after admission to the hospital, he experienced a generalized tonic-clonic seizure. This patient's impairment must include the following components: single seizure, orbital fracture, infraorbital neuropathy, anosmia, headache, and memory complaints. The article shows how the ratable impairments are combined using the Combining Impairment Ratings section. Because this patient has not experienced any seizures since the first occurrence, according to the AMA Guides he is not experiencing the “episodic neurological impairments” required for disability. Complex cases such as the one presented here highlight the need to use the criteria and estimates that are located in several sections of the AMA Guides.

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