Middle Turbinate Preservation in Endoscopic Transsphenoidal Surgery of the Anterior Skull Base

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

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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 Role of Endoscopic Transsphenoidal Surgery in the Management of Complex Lesions Involving the Skull Base

Transsphenoidal Surgery ◽

10.1007/978-3-319-56691-7_17 ◽

2017 ◽

pp. 277-302

Author(s):

James K. Liu ◽

Eleonora F. Spinazzi ◽

Jean Anderson Eloy ◽

William T. Couldwell

Keyword(s):

Skull Base ◽

Transsphenoidal Surgery ◽

Endoscopic Transsphenoidal Surgery ◽

Complex Lesions

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Vascularized Pericranial Flap for Endonasal Anterior Skull Base Reconstruction

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1721816 ◽

2021 ◽

Author(s):

Jonathan Giurintano ◽

Michael W. McDermott ◽

Ivan H. El-Sayed

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

San Francisco ◽

Middle Turbinate ◽

Cranial Base ◽

Anterior Skull Base ◽

Craniofacial Resection ◽

Skull Base Reconstruction ◽

Pericranial Flap ◽

Anterior Cranial Base

Abstract Importance As the limits of advanced skull base malignancies that can be managed through an endoscopic endonasal approach continue to be expanded, the resultant anterior skull base defects are of increasing size and complexity. In the absence of nasoseptal or turbinate flaps, the vascularized pericranial flap has been employed at our institution with excellent results. Objective The study aimed to review the outcomes of patients who underwent endonasal anterior craniofacial resection with anterior skull base reconstruction using a vascularized pericranial flap. Design Retrospective chart review of patients treated by the University of California – San Francisco minimally invasive skull base service from the years 2011 to 2017. Average duration of follow-up was 16.4 months. Setting This study was conducted at Academic tertiary referral center. Participants A total of nine patients with advanced anterior cranial base malignancies were identified who were treated with a minimally invasive, endoscopic anterior craniofacial resection from the years 2011 to 2017. Due to the nature of the resection in these patients, nasoseptal flaps and inferior/middle turbinate flaps were unavailable or insufficient for anterior skull base defect repair. Each patient underwent reconstruction of the anterior cranial base defect using an anteriorly based pericranial flap harvested by bicoronal incision, and tunneled anteriorly to the nasal cavity through a frontoethmoidal incision.

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Infectious Complications of Expanded Endoscopic Transsphenoidal Surgery: A Retrospective Cohort Analysis of 100 Cases

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1696999 ◽

2019 ◽

Vol 81 (05) ◽

pp. 497-504

Author(s):

Seung J. Lee ◽

Justin Cohen ◽

Julie Chan ◽

Evan Walgama ◽

Arthur Wu ◽

...

Keyword(s):

Los Angeles ◽

Skull Base ◽

Transsphenoidal Surgery ◽

Medical Center ◽

Cohort Analysis ◽

Significant Risk ◽

Csf Leak ◽

Patient Specific ◽

Endoscopic Transsphenoidal Surgery ◽

Presumptive Diagnosis

Abstract Objective To identify perioperative factors that may predict postoperative cerebrospinal fluid (CSF) leak and meningitis following expanded endoscopic transsphenoidal surgery (EETS). Study Design This is a retrospective study. This study was set at the Cedars-Sinai Medical Center, Los Angeles. A total of 78 patients who underwent EETS between January 2007 and November 2018 were participated. The main outcome measures were CSF leak and meningitis. Results A total of 78 patients underwent a total of 100 EETS procedures; 17.9 and 10.3% of patients developed postoperative CSF leaks and meningitis, respectively. Out of eight, three patients with meningitis did not develop an observable CSF leak. The risk of developing meningitis in patients with a CSF leak was significantly higher than those without a leak, with an odds ratio (OR) of 11.48 (95% confidence interval, 2.33–56.47; p = 0.004). Pituicytomas were significantly associated with meningitis compared with other pathologies. No other patient-specific factors were identified as risks for leak or meningitis, including method of skull base repair, sex, tumor volume, or body mass index, although there was a strong trend toward reduced CSF leak rates in patient with nasoseptal flaps used for skull base repair, compared with those without (9.5 vs. 25%). CSF protein was consistently elevated on the first CSF values obtained when meningitis was suspected. Conclusion CSF leak and meningitis are common complications of expanded endonasal surgery No statistically significant risk factors for developing a postoperative leak other than the pathology of pituicytoma were identified, including method of skull base repair, although the use of a vascularized nasoseptal flap did trend toward a reduced CSF leak rate. CSF protein is the most sensitive marker for the presumptive diagnosis and timely treatment of meningitis.

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Endonasal endoscopic repair of anterior skull-base fistulas: the Kuala Lumpur experience

The Journal of Laryngology & Otology ◽

10.1258/002221505774783421 ◽

2005 ◽

Vol 119 (11) ◽

pp. 866-874 ◽

Cited By ~ 20

Author(s):

B S Gendeh ◽

A Mazita ◽

B M Selladurai ◽

T Jegan ◽

J Jeevanan ◽

...

Keyword(s):

Skull Base ◽

Middle Turbinate ◽

Pituitary Surgery ◽

Fascia Lata ◽

Anterior Skull Base ◽

Endoscopic Procedure ◽

Sinus Surgery ◽

Kuala Lumpur ◽

Endoscopic Repair ◽

Tertiary Referral Centre

The purpose of this retrospective study is to determine the pattern of cerebrospinal fluid (CSF) rhinorrhoea presenting to our tertiary referral centre in Kuala Lumpur and to assess the clinical outcomes of endonasal endoscopic surgery for repair of anterior skull base fistulas. Sixteen patients were treated between 1998 and 2004. The aetiology of the condition was spontaneous in seven and acquired in nine patients. In the acquired category, three patients had accidental trauma and this was iatrogenic in six patients (five post pituitary surgery), with one post endoscopic sinus surgery (ESS). Imaging included computed tomography (CT) scan and magnetic resonance imaging (MRI). Endoscopic repair is less suited for defects in the frontal sinuses with prominent lateral extension and defects greater than 1.5 cm in diameter involving the skull base. Fascia lata, middle turbinate mucosa, nasal perichondrium and ear fat (’bath plug’) were the preferred repair materials in the anterior skull base, whereas fascia lata, cartilage and abdominal fat obliteration was preferentially used in the sphenoid leak repair. Intrathecal sodium flourescein helped to confirm the site of CSF fistula in 81.3 per cent of the patients. Ninety per cent of the patients who underwent ’bath plug’ repair were successful. The overall success rate for a primary endoscopic procedure was 87.5 per cent, although in two cases a second endoscopic procedure was required for closure. In the majority of cases endoscopic repair was successful, and this avoids many of the complications associated with craniotomy, particularly in a young population. Therefore it is our preferred option, but an alternative procedure should be utilized should this prove necessary.

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