Outcomes of Middle Turbinate Flap in the Reconstruction of Non-tumorous Ventral Skull Base Defects - an Institutional Review

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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Closure of large skull base defects after endoscopic transnasal craniotomy

Journal of Neurosurgery ◽

10.3171/2008.8.jns08236 ◽

2009 ◽

Vol 111 (2) ◽

pp. 371-379 ◽

Cited By ~ 53

Author(s):

Richard J. Harvey ◽

João F. Nogueira ◽

Rodney J. Schlosser ◽

Sunil J. Patel ◽

Eduardo Vellutini ◽

...

Keyword(s):

Skull Base ◽

Csf Leak ◽

Dural Defect ◽

Medical Centers ◽

Dural Defects ◽

Ventral Skull Base ◽

Skull Base Defects ◽

Reconstructive Techniques ◽

Csf Leaks

Object The authors describe the utility of and outcomes after endoscopic transnasal craniotomy and skull reconstruction in the management of skull base pathologies. Methods The authors conducted a observational study of patients undergoing totally endoscopic, transnasal, transdural surgery. The patients included in the study underwent treatment over a 12-month period at 2 tertiary medical centers. The pathological entity, region of the ventral skull base resected, and size of the dural defect were recorded. Approach-related complications were documented, as well as CSF leaks, infections, bleeding-related complications, and any minor complications. Results Thirty consecutive patients were assessed during the study period. The patients had a mean age of 45.5 ± 20.2 years and a mean follow-up period of 182.4 ± 97.5 days. The dural defects reconstructed were as large as 5.5 cm (mean 2.49 ± 1.36 cm). One patient (3.3%) had a CSF leak that was managed endoscopically. Two patients had epistaxis that required further care, but there were no complications related to intracranial infections or bleeding. Some minor sinonasal complications occurred. Conclusions Skull base endoscopic reconstructive techniques have significantly advanced in the past decade. The use of pedicled mucosal flaps in the reconstruction of large dural defects resulting from an endoscopic transnasal craniotomy permits a robust repair. The CSF leak rate in this study is comparable to that achieved in open approaches. The ability to manage the skull base defects successfully with this approach greatly increases the utility of transnasal endoscopic surgery.

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Middle turbinate mucosal flap: A low‐morbidity option in the management of skull base defects

Head & Neck ◽

10.1002/hed.26613 ◽

2021 ◽

Author(s):

Claudio Carnevale ◽

Guillermo Til‐Pérez ◽

Manuel Tomás‐Barberán ◽

Javier Ibañez‐Domínguez ◽

Diego Arancibia‐Tagle ◽

...

Keyword(s):

Skull Base ◽

Middle Turbinate ◽

Mucosal Flap ◽

Skull Base Defects

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Management of Skull Base Defects After Surgical Resection of Sinonasal and Ventral Skull Base Malignancies

Otolaryngologic Clinics of North America ◽

10.1016/j.otc.2016.12.013 ◽

2017 ◽

Vol 50 (2) ◽

pp. 397-417 ◽

Cited By ~ 9

Author(s):

Jean Anderson Eloy ◽

Emily Marchiano ◽

Alejandro Vázquez ◽

Michael J. Pfisterer ◽

Leila J. Mady ◽

...

Keyword(s):

Skull Base ◽

Surgical Resection ◽

Ventral Skull Base ◽

Skull Base Defects

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“Parachute” Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base

The Laryngoscope ◽

10.1002/lary.28660 ◽

2020 ◽

Vol 130 (12) ◽

pp. 2791-2794

Author(s):

Valentin Favier ◽

Johnny Youssef ◽

Romain Kania ◽

Benjamin Vérillaud ◽

Philippe Herman

Keyword(s):

Skull Base ◽

Ventral Skull Base ◽

Skull Base Defects

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Vascularized middle turbinate mucoperiosteal flap in skull base defects: follow-up analysis of 20 cases

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20164786 ◽

2016 ◽

Vol 3 (1) ◽

pp. 71 ◽

Cited By ~ 1

Author(s):

Shibu George ◽

Sandeep Suresh

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Middle Turbinate ◽

Benign Intracranial Hypertension ◽

Nasoseptal Flap ◽

Csf Rhinorrhea ◽

Endoscopic Closure ◽

Mucoperiosteal Flap ◽

Skull Base Defects

Background: Vascularized flaps are preferred in repair of skull base defects since they provide quality tissue volume and allow rapid healing. Though nasoseptal flap is the gold standard it may not be available always and has its own share of pitfalls; this makes the middle turbinate flap a viable alternative. This descriptive study was designed to analyze the efficacy of middle turbinate flap in endoscopic closure of skull base defects and to define indications and limitations of the flap.Methods: 20 patients who underwent endoscopic closure of small and medium sized skull base defects using middle turbinate mucoperiosteal flap were analyzed and followed up. Etiology, presentation, site and co-morbidities associated with such defects were studied. Effectiveness of closure was analyzed by the ability to cover fully, graft uptake and complications. Results: Successful flap take up was noted in all 20 cases (100%) on long term follow up; transient cerebrospinal fluid leak was observed in 1case (5%) during the immediate post-operative period which subsided fully. Spontaneous CSF rhinorrhea (n=11 [55%]) was the most common indication for closure and unilateral watery rhinorrhea was the commonest presentation (n=13 [65%]). Benign intracranial hypertension was found to have significant association with cerebrospinal fluid rhinorrhea. Most common site of leak was the medial lamella of cribriform plate (n=11 [55%]).Conclusions: Middle turbinate flap is an effective alternative to nasoseptal flap for small and medium sized anterior skull base defects; efficacy in larger defects and posterior sellar defects cannot be substantiated.

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The Buccal Flap Pad Vascularized Rotational Flap for Reconstruction of Ventral Skull Base Defects

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0035-1546636 ◽

2015 ◽

Vol 76 (S 01) ◽

Author(s):

Jeff Markey ◽

Arnau Benet ◽

Ivan El-Sayed

Keyword(s):

Skull Base ◽

Rotational Flap ◽

Buccal Flap ◽

Ventral Skull Base ◽

Skull Base Defects

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Endoscopic reconstruction of large anterior skull base defects with opening of the sellar diaphragm. Experience at a tertiary level university hospital

The Journal of Laryngology & Otology ◽

10.1017/s0022215119001841 ◽

2019 ◽

Vol 133 (10) ◽

pp. 889-894

Author(s):

C Carnevale ◽

M Tomás-Barberán ◽

G Til-Pérez ◽

J Ibañez-Domínguez ◽

D Arancibia-Tagle ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Middle Turbinate ◽

Cerebrospinal Fluid Leak ◽

Lateral Wall ◽

Anterior Skull Base ◽

University Hospital ◽

Endoscopic Reconstruction ◽

Skull Base Defects ◽

Fluid Leak

AbstractBackgroundThe indications for expanded endoscopic transnasal approaches continue to increase, with more complex skull base defects needing to be repaired. This study reviews the management of large anterior skull base defects with opening of the sellar diaphragm.MethodA prospective analysis of endonasal endoscopic surgery carried out at Son Espases University Hospital between January 2013 and December 2018 was performed. The analysis included only the cases with a significative intra-operative cerebrospinal fluid leak. In all cases, reconstruction was performed by combining the gasket seal technique with a pedicled mucosal endonasal flap.ResultsTwenty-eight patients were included. The mucoperiosteal nasoseptal flap, the lateral wall flap and the middle turbinate flap were used in 13, 8 and 7 patients, respectively, combined with the gasket seal technique. One case of post-operative cerebrospinal fluid leak was observed (3.57 per cent).ConclusionThe combination of a gasket seal with an endonasal mucosal flap is an excellent technique for repairing large anterior skull base defects.

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Treatment of anterior skull base defects by a transnasal endoscopic approach in children

Journal of Neurosurgery Pediatrics ◽

10.3171/2010.8.peds09325 ◽

2010 ◽

Vol 6 (5) ◽

pp. 459-463 ◽

Cited By ~ 33

Author(s):

Federico Di Rocco ◽

Vincent Couloigner ◽

Patricia Dastoli ◽

Christian Sainte-Rose ◽

Michel Zerah ◽

...

Keyword(s):

Skull Base ◽

Middle Turbinate ◽

Anterior Skull Base ◽

Endoscopic Approach ◽

Csf Leak ◽

Endoscopic Management ◽

Tertiary Referral Center ◽

Transnasal Endoscopic Approach ◽

Skull Base Defect ◽

Skull Base Defects

Object The object of this study was to assess the efficacy and complications of endoscopic management of anterior skull base defects. Method The authors reviewed the medical records of 28 children (20 boys and 8 girls) undergoing endoscopic repair of anterior skull base defects in their tertiary referral center between 2001 and 2008; 18 cases were congenital and 10 cases posttraumatic. During the endoscopic procedure, rigid telescopes—2.7 or 4 mm in diameter, with 0° or 30° lenses—were used. In 23 patients the anterior skull base defect was sealed with fragments of middle turbinate (bone and mucosa). In the remaining 5 patients it was sealed with cartilage harvested from the nasal septum (3 cases) or from the auricle (2 cases), fibrin glue, and oxidized cellulose. A combined external and endoscopic approach was required in 3 cases because of the size and extensions of the encephalocele. Outcome was primarily assessed by means of clinical examination, nasal fibroscopy, and imaging. Results The mean duration of follow-up was 26.7 months (range 9–57 months). One patient treated by a combined approach died of meningitis 2 years after surgery. In the remaining 27 patients, there was no recurrence of CSF leak, meningitis, or encephalocele. An iatrogenic frontal or ethmoidal mucocele was observed in 4 cases. Conclusions The endoscopic approach is a minimally invasive, safe, and efficient technique for removing nasal encephaloceles in children.

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Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1713772 ◽

2021 ◽

Author(s):

Douglas J. Totten ◽

Nauman F. Manzoor ◽

Kristen L. Yancey ◽

Robert J. Yawn ◽

David S. Haynes ◽

...

Keyword(s):

Skull Base ◽

Tumor Resection ◽

Retrospective Chart Review ◽

Csf Leak ◽

Skull Base Reconstruction ◽

Institutional Review ◽

Lateral Skull Base ◽

Cranial Fossa ◽

Small Intestinal ◽

Skull Base Defects

Abstract Objective To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting Set at the tertiary skull base center. Methods This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases (p = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.

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