scholarly journals “NIMS” nasal mucoperiosteal flap for sublabial trans-sphenoidal surgical defect repair: A new technique under microscope

2021 ◽  
Vol 12 ◽  
pp. 509
Author(s):  
Rajesh Alugolu ◽  
Vasundhara Rangan ◽  
Raghu Ram ◽  
M. Vijaya Saradhi
Keyword(s):  
Pituitary Tumors ◽  
Cranial Base ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
The World ◽  
Mucoperiosteal Flap ◽  
Defect Repair ◽  
Cranial Base Surgery ◽  
Skull Base Defect ◽  
A New Technique

Background: CSF rhinorrhea is a known complication that may occur after cranial base surgery, especially the trans-sphenoidal approaches to sellar tumors. It may occur following both microscopic and endoscopic procedures. Over a period, the balance has tilted toward endoscopy due to development of pedicled Hadad flap. Microscopic trans-sphenoidal surgery (TSS) continues to be performed in our institute as well as many other centers across the world due to familiarity of technique and unavailability of endoscopic equipment. Despite the fairly widespread use of this surgery, literature is devoid of any description of a local mucosal flap for repair of the surgical defect in microscopic TSS. Methods: We herein described the procedure and our experience of harvesting such flap in 42 patients operated for pituitary adenomas in our department between September 2016 and February 2020, through microscopic sublabial TSS. Results: All 42 of the patients included in this study underwent excision of pituitary tumors (macroadenomas). Thirty-nine (n = 39) patients were undergoing 1st time surgery, while three (n = 3) of these patients were undergoing second surgery following an earlier trans nasal trans-sphenoidal route. None of our cases have reported CSF leak postoperatively. Conclusion: This study attempts to highlight to ardent/obligate microscopic surgeons that a local vascularized flap can be harvested for repair of skull base defect and prevent postoperative CSF leak in microscopic sublabial TSS.

scholarly journals Snare technique for the remodeling of the redundant arachnoid pouch to prevent cerebrospinal fluid rhinorrhea and hematoma collection during transsphenoidal surgery for suprasellar-extended pituitary tumors

2016 ◽  
Vol 125 (6) ◽  
pp. 1443-1450 ◽  
Author(s):  
Ju Hyung Moon ◽  
Eui Hyun Kim ◽  
Sun Ho Kim
Keyword(s):  
Transsphenoidal Surgery ◽  
Tumor Resection ◽  
Pituitary Tumors ◽  
Csf Leak ◽  
Arachnoid Membrane ◽  
Csf Rhinorrhea ◽  
Resection Cavity ◽  
Postoperative Hematoma ◽  
Csf Leakage ◽  
Suprasellar Extension

OBJECTIVE Transsphenoidal surgery (TSS) is considered a most effective treatment for pituitary tumors with huge suprasellar extension. However, the chance of developing CSF leakage is relatively high, because tearing of the arachnoid membrane is common and there could be multiple tear points during the dissection of suprasellar tumors from the overlying arachnoid membrane. If there are multiple leaking points in the arachnoid membrane packing methods such as using fat or multilayered fascia graft may not be sufficient to seal off the leaking points. Moreover, the packing material may not provide sufficient tamponade to stop bleeding, and thus generates postoperative hematoma formation in the tumor resection cavity. To prevent these complications, the authors have developed a new technique for remodeling the redundant arachnoid pouch (the so-called snare technique) to reconstruct the diaphragm, seal off the CSF leak points completely, and reduce the dead space in the tumor resection cavity. METHODS In 9 patients with huge macroadenomas (> 2.5 cm in diameter) with suprasellar extension, the snare technique was used to remodel the arachnoid pouch after tumor removal via standard TSS between July 2009 and August 2014. Complications were investigated, including postoperative CSF rhinorrhea, postoperative hematoma collection, and visual compromise. RESULTS During the resection of the tumor, CSF leakage was encountered in 8 cases, all of which were sealed off using the snare technique. In 1 case without intraoperative CSF leakage, the snare technique was also applied after intentional puncturing of the arachnoid membrane to reduce the volume and tension of the arachnoid pouch. None of the 9 patients experienced postoperative CSF rhinorrhea. Lumbar CSF drainage was not required in any case. Magnetic resonance imaging studies performed 24 hours after surgery revealed a remarkable reduction in the height of the diaphragm in all cases. Visual deficits improved in all patients immediately after surgery. CONCLUSIONS Remodeling of the arachnoid pouch using the snare technique is simple and effective for completely sealing off the CSF leak point and preventing hematoma collection in the tumor resection cavity after TSS for huge pituitary tumors with suprasellar extension.

Endonasal Endoscopic Closure of Cerebrospinal Fluid Fistulas at the Anterior Cranial Base

1996 ◽  
Vol 105 (8) ◽  
pp. 620-623 ◽  
Author(s):  
Mislav Gjuric ◽  
Henning Keimer ◽  
Ulrich Goede ◽  
Malte Erik Wigand
Keyword(s):  
Cerebrospinal Fluid ◽  
Soft Tissue Injuries ◽  
Inferior Turbinate ◽  
Cranial Base ◽  
Csf Leak ◽  
Facial Soft Tissue ◽  
Csf Rhinorrhea ◽  
Endoscopic Closure ◽  
Anterior Cranial Base ◽  
Dural Tears

This study reports our indications and limits for endonasal endoscopic closure of dural defects with a cerebrospinal fluid (CSF) leak at the anterior cranial base, and demonstrates our surgical technique. Fifty-three patients with CSF rhinorrhea were reassessed for the success rate of closure of the CSF leak. Surgery was successful in 98%, and 68% of fistulas were closed endoscopically. A free graft of autogenous mucoperiosteum of the inferior turbinate was the most frequently used tissue for defect closure. The endonasal endoscopic route proved relatively safe for the closure of dural tears, irrespective of the cause, up to about 10 × 10 mm. It is characterized by minimal morbidity because of the preservation of sinus ventilation and bony structures, supraorbital nerves, and olfactory fibers. Defects larger in size, predominantly of traumatic origin, were closed via the transfacial approach. The decision on the surgical approach was additionally based on the extent of the facial soft tissue injuries and the localization of the leak.

Excavating Meningoencephaloceles: A Newly Recognized Entity

2017 ◽  
Vol 31 (2) ◽  
pp. 127-134 ◽  
Author(s):  
Patricia A. Loftus ◽  
Sarah K. Wise ◽  
Pedram Daraei ◽  
Kristen Baugnon ◽  
John M. DelGaudio
Keyword(s):  
Ct Scan ◽  
Skull Base ◽  
Operating Room ◽  
Tertiary Care ◽  
Distinct Type ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Skull Base Defect ◽  
Skull Base Defects ◽  
Csf Leaks

Background Spontaneous cerebrospinal fluid (CSF) leaks are largely attributed to idiopathic intracranial hypertension and typically present as skull base defects with or without prolapse of intracranial contents. However, in our practice, we have encountered a distinct type of spontaneous CSF leak that presents in a different manner. Objective To discuss a newly-classified, difficult to treat, subset of spontaneous CSF leaks that present as excavation of the bone of the skull base in a tunnel- or canal-like fashion by a meningocele or meningoencephalocele instead of as a localized area of bony dehiscence. Methods A retrospective review was performed at a tertiary care rhinology practice to identify a subset of CSF leak patients with an excavating/canal-like skull base defect visualized radiographically on computed tomography (CT) scan or magnetic resonance imaging and/or endoscopically in the operating room. Results The cohort of patients consisted of 7 females and 1 male with an average age of 53.6 years and a self-reported race of 4:3:1 African-American: Caucasian-Indian. All patients presented with CSF rhinorrhea. The most common leak site was the cribriform and upper septum. Six of the 8 patients had multiple defects and/or progression of their skull base defects, and 5 patients required multiple and/or repeat repairs in the operating room. Seven of the 8 patients underwent a cisternogram because the excavating nature of the leaks made it difficult to identify the specific leak site on high-resolution CT scan alone. Conclusion In spontaneous CSF leaks that are difficult to identify or recur soon after a proper repair, an excavating pattern should be considered. Failure to recognize this type of leak and all of its tributaries, to fully unroof the excavated bone to completely resect the meningocele, and to visualize and close the site of origin will likely result in failure and recurrence of CSF leak.

SURGICAL MANAGEMENT OF ANTERIOR CRANIAL BASE FRACTURES WITH CEREBROSPINAL FLUID FISTULAE

Neurosurgery ◽  
2008 ◽  
Vol 62 (2) ◽  
pp. 463-471 ◽  
Author(s):  
Martin Scholsem ◽  
Felix Scholtes ◽  
Frèderick Collignon ◽  
Pierre Robe ◽  
Annie Dubuisson ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Treatment Algorithm ◽  
Cranial Base ◽  
University Hospital ◽  
Csf Leak ◽  
Dural Tear ◽  
Csf Rhinorrhea ◽  
Csf Fistula ◽  
Associated Lesions ◽  
Anterior Cranial Base

Abstract OBJECTIVE The management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience. METHODS We retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear. RESULTS Of the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure. CONCLUSION The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.

scholarly journals Endoscopic Endonasal Excision of Pituitary Tumors Using a Mono-nostril Technique

2019 ◽  
Vol 23 (4) ◽  
Author(s):  
AMIR AZIZ ◽  
YASER-UD- DIN ◽  
ZUBAIR AHMED ◽  
SHARUKH RIZVI ◽  
HABIB SULTAN ◽  
...  
Keyword(s):  
Tumor Resection ◽  
Pituitary Tumors ◽  
Invasive Procedure ◽  
Early Discharge ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Visual Status ◽  
Good Cosmetic ◽  
Partial Excision

Objectives: The purpose of this study is to assess the effectiveness and advantage of endoscopic mono-nostril approach to the pituitary tumors.Materials and Methods: We analyzed 70 patients undergoing transsphenoidal mono-nostril excision of pituitary tumors from September, 2016 to March, 2018.Results: We operated 70 patients, out of which 51 were males and 19 were females; the age of the patients ranged from 15 years to 65 years.In our study, out of 70 patients, 61 (87.1%) patients had excellent results with total tumor resection, marked visual improvement, early discharge on the second post-operative day, resuming their daily activities within two weeks and recurrence free interval of 1 year. Nine (12.8%) of our patients had a partial excision of the tumor, whereby there was improvement of headaches in all of them while visual status remained at the pre-operative status. Five (7.1%) of our patients had a post-operative cerebral spinal fluid (CSF) rhinorrhea, 4 (5.7%) in total excision group and 1 (1.4%) in partial excision group. These patients of CSF leak were retained in hospital and their mean stay in hospital was 12  4. Conclusion: We consider that endoscopic mono-nostril excision of the pituitary tumor is a relatively safer, effective, minimally invasive procedure; whereby there is a fast recovery, early discharge and good cosmetic results.

Synergistic Imaging: A New Technique to Assist the Planning of Cranial Base Surgery

2015 ◽  
pp. 14-17
Author(s):  
J. E. Crossman ◽  
D. L. G. Hill ◽  
D. J. Hawkes ◽  
T. S. C. Cox ◽  
P. E. Graves ◽  
...  
Keyword(s):  
Cranial Base ◽  
New Technique ◽  
Cranial Base Surgery ◽  
A New Technique

Endoscopic Reconstruction of the Cranial Base Using a Pedicled Nasoseptal Flap

2008 ◽  
Vol 63 (suppl_1) ◽  
pp. ONS44-ONS53 ◽  
Author(s):  
Amin B. Kassam ◽  
Ajith Thomas ◽  
Ricardo L. Carrau ◽  
Carl H. Snyderman ◽  
Allan Vescan ◽  
...  
Keyword(s):  
Donor Site ◽  
Cranial Base ◽  
Leak Rate ◽  
Original Position ◽  
Csf Leak ◽  
Wound Complications ◽  
Harvesting Technique ◽  
Cranial Base Surgery ◽  
Reconstructive Technique ◽  
Csf Leaks

Abstract Objective: Reconstruction of the cranial base using vascularized tissue promotes rapid and complete healing, thus avoiding complications caused by persistent communication between the cranial cavity and the sinonasal tract. The Hadad-Bassagasteguy flap (HBF), a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, seems to be advantageous for the reconstruction of the cranial base after endonasal cranial base surgery Methods: We performed a retrospective review of patients who underwent endonasal cranial base surgery at the University of Pittsburgh Medical Center from January 30, 2006 to January 30, 2007, identifying patients who experienced reconstruction with a vascularized septal mucosal flap (HBF). We analyzed the demographic data, pathological characteristics, site and extent of resection, use of cerebrospinal fluid (CSF) diversion techniques, and outcome. Results: Seventy-five patients who underwent endonasal cranial base endoscopic surgery received repair with the HBF. In this population, we encountered eight postoperative CSF leaks (10.66%), all in patients who required intra-arachnoidal dissection. When we correct the statistical analysis to include only patients with intra-arachnoidal lesions, the postoperative CSF leak rate is 14.5% (eight of 55 patients). It is notable that six CSF (33%) leaks occurred in our first 25 repairs, whereas we encountered only two postoperative leaks (4%) in the last 50 patients. The corrected CSF leak rate, considering only intra-arachnoidal lesions, was two (5.4%) of 37 patients. This improvement in the CSF leak rate reflects our growing experience and comfort with this reconstructive technique. All of our failures could be matched to a specific technical mistake In addition, we modified the flap-harvesting technique to allow for staged procedures and the removal of caudal lesions. These special circumstances require storage of the flap in the antrum during the removal of caudal lesions, and suturing of the flap in its original position for staged procedures. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with bipolar electrocautery, thereby preserving the flap blood supply. We encountered no infectious or wound complications in this series of patients. The donor site accumulates crusting, which requires debridement until mucosalization is complete; this usually occurs 6 to 12 weeks after surgery. Conclusion: The HBF is a versatile and reliable reconstructive technique for repairing defects of the anterior, middle, clival, and parasellar cranial base. Its use has resulted in a significant decrease in our incidence of CSF leaks after endonasal cranial base surgery. Attention to technical details is of paramount importance to achieve the best outcomes.

Study on Closure of Skull Base Defect Post–Endoscopic Endonasal Transsphenoid Pituitary Surgery: A Novel Flap Design

2019 ◽  
Author(s):  
Gokul Gopi ◽  
Saurav Sarkar ◽  
Sudipta Mohakud ◽  
Ashis Patnaik ◽  
Sumit Bansal ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Fascial Closure ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Flap Repair ◽  
Skull Base Defect ◽  
Nasal Septal Flap

Abstract Objective This study was aimed to compare the closure of skull base defect in endoscopic endonasal transsphenoid surgery of pituitary tumors, using bipedicled nasal septal flap versus fascial closure. The study hypothesis being that bipedicled nasal septal flap is better, compared with fascial closure of skull base defect post–endoscopic endonasal transsphenoid surgery of pituitary tumors. Methods All the eligible patients were randomly divided into two groups and then randomly allocated to the surgeons. In one group, fat and fascia lata was used for closure of the skull base defect and nasal septal flap was not harvested whereas in the other, nasal septal flap was used for closure. Result There was a statistically significant difference in postoperative cerebrospinal fluid leak between the two groups. Patients who had undergone flap repair had lower incidence of postoperative cerebrospinal fluid (CSF) leak. Duration of postoperative hospital stay was also less among the group who underwent flap repair (statistically significant). Conclusion Bipedicled nasal septal flap serves an excellent cover for the skull base defect following endoscopic endonasal transsphenoidal pituitary surgery. It can prevent postoperative CSF leak even in cases where tissue glue is not used.

Safety of Low-Dose Intrathecal Fluorescein in Endoscopic Cranial Base Surgery

2007 ◽  
Vol 61 (suppl_3) ◽  
pp. ONS-161-ONS-166 ◽  
Author(s):  
Dimitris G. Placantonakis ◽  
Abtin Tabaee ◽  
Vijay K. Anand ◽  
David Hiltzik ◽  
Theodore H. Schwartz
Keyword(s):  
Lower Extremity ◽  
Low Dose ◽  
Cranial Base ◽  
Csf Leak ◽  
Reconstruction Technique ◽  
Lower Extremity Weakness ◽  
Lumbar Drainage ◽  
Anterior Cranial Base ◽  
Csf Leakage ◽  
Cranial Base Surgery

AbstractObjective:Intraoperative identification of cerebrospinal fluid (CSF) leakage is critical in successful closure after endoscopic cranial base surgery. Intrathecal injection of fluorescein is quite useful in identifying CSF leaks. However, complications have been reported with various doses and the technique has fallen out of favor. We explored the safety of low-dose intrathecal fluorescein administered to patients undergoing endoscopic cranial base surgery.Methods:A retrospective chart review and postoperative patient survey were performed. The nature and incidence of complications and subjective complaints were recorded in 54 patients who underwent endoscopic, endonasal approaches to the anterior cranial base and received intrathecal fluorescein after premedication with dexamethasone and diphenhydramine.Results:Intraoperative CSF leak was identified with fluorescein in 46.3% of the patients and helped determine the reconstruction technique. Postoperative CSF leak occurred in 9.3% of the patients and resolved with lumbar drainage. There were no seizures. Most side effects were nonspecific, transient, and likely not caused by fluorescein including malaise (57.4%), headache (51.9%), dizziness (31.5%), or nausea/vomiting (24.1%). Three patients (5.6%) experienced persistent subjective lower extremity weakness (n = 2) and numbness (n = 2) postoperatively; however, two of them had undergone lumbar drainage.Conclusion:Low-dose injection of intrathecal fluorescein after premedication with steroid and antihistamine agents is generally safe. Most symptoms are nonspecific and transient, likely caused by the surgery or lumbar drainage. However, fluorescein should be administered with some caution because it may be responsible for occasional lower extremity weakness and numbness.

scholarly journals Anterior Skull Base Reconstruction: Does Fat Preparation Matter?

2018 ◽  
Vol 79 (02) ◽  
pp. e31-e35 ◽  
Author(s):  
Joshua Wood ◽  
Jaron Densky ◽  
John Boughter ◽  
Merry Sebelik ◽  
Courtney Shires
Keyword(s):  
Skull Base ◽  
Anterior Skull Base ◽  
Fat Graft ◽  
Csf Leak ◽  
Surgical Time ◽  
Skull Base Reconstruction ◽  
Csf Rhinorrhea ◽  
Autologous Fat ◽  
Significant Difference ◽  
Skull Base Defect

Objectives This article aims (1) to determine whether there is any difference in cerebrospinal fluid (CSF) leak rate after anterior skull base autologous fat reconstruction based on how the fat is prepared, and (2) to measure impact on surgical times by reconstruction type. Design Translational animal model surgical technique 3-arm trial, comparing two different methods of autologous fat skull base reconstruction versus a nonreconstructed control group. Setting Animal study. Subjects Adult Sprague-Dawley rats. Main Outcome Measures Resolution of CSF rhinorrhea after repair of a surgically created anterior skull base defect. Results Both wet (uncompressed) and dry (compressed) fat reconstruction of an anterior skull base defect demonstrated lower CSF leak rates than nonreconstructed defects. Dry fat reconstruction achieved significance in superiority of controlling CSF leak over no reconstruction (64% success vs. 31%); while wet fat reconstruction trended toward significance (50% vs. 31%). Reconstruction procedure time was longer than nonreconstructed controls, but there was no significant difference between type of fat preparation in surgical time. Conclusions This study demonstrates that drying and compressing the fat graft improves autologous fat reconstruction success for anterior skull base defects, and does not add significantly to surgical time over nonprepared fat.

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