Endoscopic endonasal management of skull base defects in pediatric patients

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

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Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

Seminars in Plastic Surgery ◽

10.1055/s-0037-1607274 ◽

2017 ◽

Vol 31 (04) ◽

pp. 203-213 ◽

Cited By ~ 13

Author(s):

Srikant Chakravarthi ◽

Lior Gonen ◽

Alejandro Monroy-Sosa ◽

Sammy Khalili ◽

Amin Kassam

Keyword(s):

Skull Base ◽

Middle Turbinate ◽

Reconstruction Algorithm ◽

Inferior Turbinate ◽

Anterior Skull Base ◽

Endoscopic Endonasal ◽

Fascial Flap ◽

Skull Base Defects ◽

Reconstructive Techniques ◽

Csf Leaks

AbstractThe success of expanded endoscopic endonasal approaches (EEAs) to the anterior skull base, sellar, and parasellar regions has been greatly aided by the advancement in reconstructive techniques. In particular, the pedicled vascularized flaps have been developed and effectively cover skull base defects of varying sizes with a significant reduction in postoperative CSF leaks. There are two aims to this review: (1) We will provide our current, simplified reconstruction algorithm. (2) We will describe, in detail, the relevant anatomy, indications/contraindications, and surgical technique, with a particular emphasis on the nasoseptal flap (NSF). The inferior turbinate flap (ITF), middle turbinate flap (MTF), pericranial flap (PCF), and temporoparietal fascial flap (TPFF) will also be described. The NSF should be the primary option for reconstruction of majority of skull base defects following endonasal endoscopic surgery. In general, for the planum, cribriform, and upper two-thirds of the clivus, the NSF is ideal. For the lower-third of the clivus, the NSF may not be adequate and may require additional reconstructive options. Although limited in reach or more technically challenging, these reconstructive flaps should still be considered and kept in the surgical algorithm.

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The Endoscopic Endonasal Approach for Anterior Skull Base Pathology in Pediatric Patients: Outcomes and Complications

Skull Base ◽

10.1055/s-2006-958356 ◽

2007 ◽

Vol 16 (S 1) ◽

Author(s):

Ajith Thomas ◽

Amin Kassam ◽

Hillal Kanaan ◽

Carl Snyderman ◽

Ricardo Carrau ◽

...

Keyword(s):

Skull Base ◽

Pediatric Patients ◽

Anterior Skull Base ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

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Bilateral “Rescue Strip” Technique for Endoscopic Endonasal Approaches to the Clivus

Operative Neurosurgery ◽

10.1093/ons/opaa304 ◽

2020 ◽

Author(s):

Matthew Kim ◽

Marc Otten ◽

Jonathan B Overdevest ◽

David A Gudis

Keyword(s):

Skull Base ◽

Cerebrospinal Fluid Leak ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Surgical Access ◽

Flap Repairs ◽

Skull Base Defects ◽

Fluid Leak ◽

Video Demonstration ◽

Wide Access

Abstract BACKGROUND The vascularized nasoseptal flap (NSF) is a pillar of contemporary endoscopic skull base reconstruction. The pedicle for the NSF is supplied by the posterior septal branch of the sphenopalatine artery, which courses along the arch of the choana and sphenoid rostrum before entering the nasal septum. Resection or mobilization of this region is necessary for surgical access to the clivus. OBJECTIVE To describe a technique for preserving bilateral NSF pedicles during endoscopic endonasal resection of the clivus, thereby safeguarding availability of the flaps for future skull base repair needs. METHODS Report of operative technique with video demonstration. RESULTS This technique for NSF preservation allows for wide access to the clivus while saving the future option for vascularized flap repairs of skull base defects. The patient in whom we demonstrate this technique underwent complete resection of her clivus without cerebrospinal fluid leak and with preservation of both NSF pedicles. CONCLUSION The “rescue strip” technique for endonasal endoscopic clival surgery preserves the bilateral NSF pedicles for future use without compromising surgical access to the clivus.

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Immediate complications associated with high-flow cerebrospinal fluid egress during endoscopic endonasal skull base surgery

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14294 ◽

2014 ◽

Vol 37 (4) ◽

pp. E3 ◽

Cited By ~ 6

Author(s):

Edward E. Kerr ◽

Daniel M. Prevedello ◽

Ali Jamshidi ◽

Leo F. Ditzel Filho ◽

Bradley A. Otto ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Preventive Measures ◽

Skull Base Surgery ◽

High Volume ◽

High Flow ◽

Endoscopic Endonasal ◽

Tension Pneumocephalus ◽

Csf Leakage ◽

Skull Base Defects

Endoscopic expanded endonasal approaches (EEAs) to the skull base are increasingly being used to address a variety of skull base pathologies. Postoperative CSF leakage from the large skull base defects has been well described as one of the most common complications of EEAs. There are reports of associated formation of delayed subdural hematoma and tension pneumocephalus from approximately 1 week to 3 months postoperatively. However, there have been no reports of immediate complications of high-volume CSF leakage from EEA skull base surgery. The authors describe two cases of EEAs in which complications related to rapid, large-volume CSF egress through the skull base surgical defect were detected in the immediate postoperative period. Preventive measures to reduce the likelihood of these immediate complications are presented.

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