Nasal morbidity following endoscopic skull base surgery: a prospective cohort study

Impact of endoscopic craniofacial resection on simulated nasal airflow and heat transport

BACKGROUND

Endoscopic craniofacial resections (CFR) are performed for extensive anterior skull base lesions. This surgery involves removal of multiple intranasal structures, potentially leading to empty nose syndrome (ENS). However, many patients remain asymptomatic postoperatively. Our objective was to analyze the impact of CFR on nasal physiology and airflow using computational fluid dynamics (CFD). This is the first CFD analysis of post-CFR patients.

METHODS

Three-dimensional sinonasal models were constructed from 3 postoperative images using Mimics^TM . Hybrid computational meshes were created. Steady inspiratory airflow and heat transport were simulated at patient-specific flow rates using shear stress transport k-omega turbulent flow modeling in Fluent^TM . Simulated average heat flux (HF) and surface area where HF exceeded 50 W/m² (SAHF50) were compared with laminar simulations in 9 radiographically normal adults.

RESULTS

Three adults underwent CFR without developing ENS. Average HF (W/m² ) were 132.70, 134.84, and 142.60 in the CFR group, ranging from 156.24 to 234.95 in the nonoperative cohort. SAHF50 (m² ) values were 0.0087, 0.0120, and 0.0110 in the CFR group, ranging from 0.0082 to 0.0114 in the radiographically normal cohort. SAHF50 was distributed throughout the CFR cavities, with increased HF at the roof and walls compared with the nonoperative cohort.

CONCLUSION

Average HF was low in the CFR group compared with the nonoperative group. However, absence of ENS in most CFR patients may be due to large stimulated mucosal surface area, commensurate with the nonoperative cohort. Diffuse distribution of stimulated area may result from turbulent mixing after CFR. To better understand heat transport post-CFR, a larger cohort is necessary.

The Magnetic Resonance Imaging Appearance of Endoscopic Endonasal Skull Base Defect Reconstruction Using Free Mucosal Graft

OBJECTIVE

At our institution, skull base reconstruction using a free mucosal graft from the nasal cavity floor has been the standardized technique after pituitary adenoma resection via transsellar approach. In this study, the expected appearance of the reconstruction on postoperative magnetic resonance imaging (MRI) scans is described and its integrity and impact on the sinonasal cavity are assessed.

METHODS

Fifty patients were selected, and their electronic medical records were reviewed for postoperative course, Sino-Nasal Outcome Test-22 (SNOT-22) scores, and nasal endoscopy reports. A total of 116 postoperative MRI scans were available to evaluate 1) the appearance and thickness of the graft, 2) the enhancement of the graft, and 3) the T2 signal in sphenoid sinus as a potential indication for inflammatory disease.

RESULTS

There was no significant change in the thickness of the graft over time. Except for the 7 scans that were obtained without intravenous contrast, all scans showed enhancement of the graft. About half of the patients showed persistent T2 hyperintense signal at 12 and 24 months. However, this finding was not clinically significant, because postoperative SNOT-22 scores showed minimal sinonasal impact.

CONCLUSIONS

Postoperative MRI surveillance scans showed a stable appearance of the graft that mimics the native mucosa, with enhancement through time, reflecting its robust vascularization and integration to the skull base. Although persistent T2 hyperintense signal was detected in the sphenoid sinus, clinical evidence based on nasal endoscopy reports and SNOT-22 scores indicated minimal sinonasal morbidity.

Nasal Morbidity and Quality of Life After Endoscopic Transsphenoidal Surgery: A Single-Center Prospective Study

OBJECTIVE

The aim of this study was to assess nasal morbidity of endoscopic transsphenoidal approaches (ETAs) for treatment of sellar and parasellar diseases through evaluation of quality of life (QoL) and nasal function. The impact of different ETAs, according to extent and reconstruction technique, was also studied.

METHODS

Patients undergoing ETA for treatment of sellar or parasellar lesions were prospectively recruited and examined preoperatively and at 6 months after surgery according to the following workup: nasal endoscopy, rhinomanometry, acoustic rhinometry, University of Pennsylvania Smell Identification Test, Anterior Skull Base Nasal Inventory-12, Sino-nasal Outcome Test-22, and Short-Form Health Survey-36 (SF-36).

RESULTS

Of 34 patients initially recruited, 29 completed follow-up examinations. Seven patients (24.14%) developed turbinoseptal synechiae; anterior septal perforations were observed in 3 patients (10.35%). More extended surgical dissection was associated with the presence of postoperative septal perforation and synechiae. No significant difference was noted between preoperative and postoperative results on the University of Pennsylvania Smell Identification Test, acoustic rhinometry, Sino-nasal Outcome Test-22, or Anterior Skull Base Nasal Inventory-12. There was a significant increase in nasal airflow after surgery and improvement of the Short-Form Health Survey-36 score in 4 of 8 domains.

CONCLUSIONS

The modular ETA technique is associated with minimal morbidity and preserves nasal patency, airflow, and olfactory function. Quality of life is not affected and although small septal perforations and synechiae can be observed, nasal physiology is not compromised. Nonetheless, careful manipulation of sinonasal structures is recommended to minimize postoperative sequelae.

Computational fluid dynamics after endoscopic endonasal skull base surgery-possible empty nose syndrome in the context of middle turbinate resection

BACKGROUND

Empty nose syndrome (ENS) is a rare and debilitating disease with a controversial definition, etiology, and treatment. One puzzling fact is that patients who undergo an endoscopic endonasal approach (EEA) often have resection of multiple anatomic structures, yet seldom develop ENS. In this pilot study, we analyzed and compared the computational fluid dynamics (CFD) and symptoms among post-EEA patients, ENS patients, and healthy subjects.

METHODS

Computed tomography scans of 4 post-EEA patients were collected and analyzed using CFD techniques. Two patients had significant ENS symptoms based on results of the Empty Nose Syndrome 6-item Questionnaire (score >11), whereas the other 2 were asymptomatic. As a reference, their results were compared with previously published CFD results of 27 non-EEA ENS patients and 42 healthy controls.

RESULTS

Post-EEA patients with ENS symptoms had a similar nasal airflow pattern as non-EEA ENS patients. This pattern differed significantly from that of EEA patients without ENS symptoms and healthy controls. Overall, groups with ENS symptoms exhibited airflow dominant in the middle meatus region and a significantly lower percentage of airflow in the inferior turbinate region (EEA with ENS, 17.74 ± 4.00% vs EEA without ENS, 51.25 ± 3.33% [t test, p < 0.02]; non-EEA ENS, 25.8 ± 17.6%; healthy subjects, 36.5 ± 15.9%) as well as lower peak wall shear stress (EEA with ENS, 0.30 ± 0.13 Pa vs EEA without ENS, 0.61 ± 0.03 Pa [p = 0.003]; non-EEA ENS, 0.58 ± 0.24 Pa; healthy subjects, 1.18 ± 0.81 Pa).

CONCLUSION

These results suggest that turbinectomy and/or posterior septectomy may have a varying functional impact and that ENS symptoms go beyond anatomy and correlate with aerodynamic changes. The findings open the door for CFD as a potential objective diagnosis tool for ENS.

Sinonasal Quality of Life Outcomes After Extended Endonasal Approaches to the Skull Base

Introduction  Endoscopic endonasal skull base surgery (EESBS) leads to significant alterations in sinonasal anatomy and physiology. However, there is limited data available on quality of life (QOL) outcomes following EESBS. Methods  A retrospective review of patients undergoing EESBS from January 2014 to April 2017 was performed. Records were reviewed for clinical history, operative details, and 22-item Sinonasal Outcomes Test (SNOT-22) scores. Unadjusted and adjusted linear regression models were utilized to compare change in SNOT-22 scores from baseline in patients who underwent a simple sella approach (SA) or an extended beyond sella approach (BSA). Results  A total of 108 patients were in the SA group, while 61 patients were in the BSA group. SNOT-22 scores were available at baseline and 3 months for 84 patients, while 6-month scores were available for 49 patients. SNOT-22 scores for all patients were not significantly different at 3 months ( p  = 0.40) or at 6 months ( p  = 0.58). Unadjusted linear regression model did not show an association between the type of approach and change in SNOT-22 score at 3 months ( p  = 0.07) and 6 months ( p  = 0.28). Adjusted regression model showed a significant decrease in SNOT-22 scores at 3 months ( p  = 0.04) for the BSA group, but there was no significant change in SNOT-22 score at 6 months ( p  = 0.22). Conclusion  Patients undergoing EESBS had no significant change in outcomes at 3 and 6 months. A more extensive BSA was not associated with worse QOL outcomes as measured by SNOT-22.

Delayed complications from expanded endonasal surgery for intracranial tumors

PURPOSE OF REVIEW

Delayed complications after endoscopic endonasal approaches to the skull base, defined as complications greater than 1 month postoperatively, are uncommon. These complications are divided into categories including sinonasal, neuroanatomic, endocrine and vascular. This review highlights the most up-to-date advancements and reviews the management of delayed complications for skull base patients.

RECENT FINDINGS

Over the last 10 years, the field of endoscopic endonasal skull base surgery has expanded with new data highlighting the long-term patient outcomes. The majority of patients experience increased quality of life (QOL) after these interventions. However, delayed complications including alterations to sinonasal function, delayed encephaloceles from the bony skull base defect and resulting endocrinopathies can significantly impact patient's QOL. Awareness of these complications and their current management is valuable for endoscopic surgeons.

SUMMARY

Endonasal approaches to the skull base are safe and well tolerated in properly selected patients. This article highlights the delayed complications that require recognition and management by skull base surgeons to ensure the best possible care for patients.

Complications of Nasoseptal Flap Reconstruction: A Systematic Review

Objective  The nasoseptal flap (NSF) is considered the primary vascularized flap for reconstruction of dural defects with endoscopic endonasal surgery (EES) of the skull base. However, the complications and morbidities associated with this reconstructive flap are poorly understood. This article presents a systematic review of the complications and morbidities related to the use of the NSF in skull base surgery. Method  A systematic review of the literature based on published guidelines was performed to identify potential complications and morbidities related to the NSF. The MEDLINE and Embase databases were searched from January 1, 1950 to February 5, 2018. Results  Twenty-seven articles were identified. Reported complications were as follows: NSF necrosis (4 studies; [0-1.3%]), mucocele formation (5 studies; [0-3.6%]), septal perforation (6 studies, [0-14.4%]), nasal dorsum collapse (2 studies, [0.7-5.8%]), effects on quality of life (QoL) (8 studies), and olfactory loss (11 studies). Conclusion  Although complications associated with the NSF may be underreported in the literature, the NSF appears to be a safe and reliable reconstructive flap in EES of the skull base.

Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling

BACKGROUND

To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing.

METHODS

In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases.

RESULTS

Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion.

CONCLUSION

This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.

How I do it: endoscopic endonasal approach to the inferior third of the clivus

BACKGROUND

Nowadays, endoscopic endonasal expanded approach targeting for the clival lower third is well described in literature. Nonetheless, great variations can be found among surgical groups, specially during the earlier stages of this procedure.

METHOD

We present a step by step description of the clival lower third approach until entering the dural space, setting its bony limits. We describe the basipharyngeal flap tailoring as a helpful option for latter reconstruction. The study of cadaveric specimens adds clarifying dissections.

CONCLUSIONS

The expansion in the coronal plane is providential in most of the intradural lesions of the inferior clivus. Basipharyngeal flap may help seal the surgical defects in this area.

The application of a free nasal floor mucoperiosteal graft in endoscopic sinus surgery

BACKGROUND

Numerous reconstructive techniques and materials have been reported for repair of skull base defects, cerebrospinal fluid (CSF) leaks, and coverage of denuded bone, including pedicled vascularized flaps and free mucosal grafts.

OBJECTIVE

This study described our technique of harvesting and transferring a free nasal floor mucoperiosteal graft and discussed our experience with the application of this technique.

METHODS

A retrospective review of 19 patients (mean age, 53.7 years; 13 men, 6 women) treated with image-guided endoscopic sinus surgery for chronic rhinosinusitis or tumors. Intraoperative free mucosal graft repair was performed for large skull base defects after resection of skull base tumor (n = 7), CSF leak (n = 12), and iatrogenic CSF leak (n = 7). Repair was performed in an overlay or an underlay fashion, with a multilayer approach in cases of a large skull base defect. Patients underwent endoscopic assessment at 6 days, 5 weeks, and 12 weeks after surgery for assessment of healing and of CSF leak. The patients were followed up for a mean of 8.7 months.

RESULTS

Minimal crusting was identified at the donor site in all the patients at 6 days, with no evidence of CSF leak. In cases of exposed bone and/or mucosal stripping, hyperostosis at the recipient graft site was avoided. All the patients had complete healing at the donor site and the recipient site, with minimal morbidity at 5 and 12 weeks, and no evidence of recurrent CSF leak.

CONCLUSION

The use of nasal floor mucoperiosteal free grafts in endoscopic surgery offered the advantage of ease of harvest, coverage of large defects, and multiple applications of use, with minimal donor-site morbidity.

Evolution of sinonasal symptoms and mucosal healing after minimally invasive pituitary surgery

BACKGROUND

Minimally invasive pituitary surgery (MIPS) via endoscopy has become widely accepted as the surgical paradigm of choice for pituitary pathology. The objective of the current study was to analyze the evolution of symptom scores and mucosal healing after MIPS.

METHODS

The 22-item Sino-Nasal Outcome Test (SNOT-22) scores and objective endoscopic data of 52 patients were reviewed in a longitudinal manner. Scaled averages of the SNOT-22 and endoscopic scores from different time points were compared with baseline scores by using nonparametric testing. The time to baseline for endoscopic examinations was also analyzed by using Kaplan-Meier curves.

RESULTS

The rhinologic symptoms subdomain of the SNOT-22 scores showed statistically significant worsening between baseline and 2 weeks after surgery (p = 0.03). Follow-up SNOT-22 scores after 2 weeks showed no significant differences compared with baseline scores, with an overall trend toward improvement in patient symptoms during the subsequent period. Similar analysis for the endoscopic data illustrated statistically significant differences from the baseline scores up to 16 weeks after surgery. The overall trend showed a worsened endoscopic examination, initially with a spike at ∼8 to 10 weeks (p = 0.03) and with a subsequent return to baseline. The Kaplan-Meier estimate curve demonstrated a median time to return to baseline endoscopy at 18.9 weeks (95% confidence interval, 14.9-38.3 weeks).

CONCLUSION

The longitudinal data exhibited subjective improvement of patient outcomes based on SNOT-22 scores within 2-4 weeks after MIPS. However, the objective endoscopic data revealed a lag in improvement of the examination, typically at 16-20 weeks, which underscores ongoing careful endoscopic assessment and management to ensure proper mucosal healing beyond just subjective symptoms as the gauge to postoperative recovery.

The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas

Background:

While effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and can result in a several-week period of postoperative crusting during re-mucosalization of the denuded nasal septum. Endoscopic transsphenoidal surgery for pituitary adenoma resection is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas. This flap is raised in all surgeries during the transnasal exposure using septal mucoperiosteum that would otherwise be discarded during the posterior septectomy performed in binostril approaches.

Methods:

We present a retrospective, consecutive case series of 43 patients undergoing endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure. Main outcome measures were extent of resection and postoperative CSF leak.

Results:

The mean extent of resection was 97.16 ± 1.03%. Radiographic measurement showed flap length to be adequate. While a defect in the diaphragma sellae and CSF leak were identified in 21 patients during surgery, postoperative CSF leak occurred in only one patient.

Conclusions:

The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly always successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. The flap is raised from mucoperiosteum lining the posterior nasal septum, which is otherwise resected during posterior septectomy. Because the anterior septal cartilage is not denuded, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap.

Transoral screw and wire fixation for unstable anterior ½ atlas fracture

Study Design:

Atlas fractures are evaluated according to the fracture type and ligamentous injury. External immobilization may result in fracture nonunion.

Objective:

The ideal treatment method for non-stabilized atlas fractures is limited fixation without restricting the range of motion of the atlantoaxial and atlantooccipital joints.

Summary of Background Data:

Such a result can be established by using either anterior fixation or posterior lateral mass fixation. However, none of these techniques can fully address anterior 1/2 atlas fractures such as in this case.

Materials and Methods:

A transoral technique in which bilateral screws were placed intralaminarly and connected with wire was used to reduce and stabilize an anterior 1/2 fracture of C1.

Result:

Radiological studies after the surgery showed good cervical alignment, no screw or wire failure and good reduction with fusion of anterior arcus of C1.

Conclusions:

Internal immobilization by this screw and wire osteosynthesis technique protects the mobility of the atlanto-occipital and atlantoaxial joints. The main advantage is that neither the twisted wires inserted under the anterior lamina, nor the laterally placed screw heads interfere with midline wound closure; unlike the plate/cage and rod systems used together with anterior screws. A computer navigation system with intraoperative 3D imaging facilities will be of benefit for safe placement of the screw, however we preferred a free-hand technique, as the starting point was at the fracture line along the trajectory of the routinely accessible anterior lamina.

Endoscopic Endonasal Transsphenoidal Approach From the Surgeon Point of View

OBJECTIVE

In February 2009, the authors' center formed a team of neurosurgeons, otolaryngologists, endocrinologists, and radiologists to perform pituitary surgery using the endoscopic endonasal transsphenoidal approach (EETSA). This paper reviews the authors' experience with the technique, pathological outcomes, hormone profiles, and postoperative complications.

METHODS

Between February 2009 and December 2015, 535 patients underwent the EETSA with 2-nostrils/4-hands surgery. All of the patients had preoperative neurophthalmological and endocrinological assessments and neuroimaging. Patients were followed for at least 6 months with otolaryngological evaluations.

RESULTS

The most common pathology treated was pituitary adenomas, with 390 (72.9%) patients. Of these, 287 (73.6%) were nonfunctioning adenomas. As the surgical method, the conventional 2-nostrils/4-hands technique was performed in 77 patients (14.4%), a right conventional nasoseptal flap and left modified nasoseptal rescue flap technique was used in 135 patients (25.2%), and bilateral modified nasoseptal rescue flaps were used in 323 patients (60.4%). Postoperative complications occurred in 46 patients (8.6%). The most common complications were vascular injury or hematoma (10 patients, 1.9%), and the most common postoperative sinonasal complaints were hyposmia or anosmia. Olfactory function was significantly decreased according to the Connecticut Chemosensory Clinical Research Center test (P <0.001) and Cross-Cultural Smell Identification Test scores (P <0.001) evaluated 6 months postoperatively.

CONCLUSIONS

Skull-base tumor surgery via an EETSA with a team approach was performed for various extended tumors. It is important to consider postoperative sinonasal dysfunction, such as hyposmia or anosmia, and to have this followed by an otolaryngologist.

Extent of Surgery in Endoscopic Transsphenoidal Skull Base Approaches and the Effects on Sinonasal Morbidity

Background

Endoscopic transsphenoidal skull base surgery (ETSS) is now considered the criterion standard approach for resection of pituitary adenomas and other midline anterior skull base lesions. Normal sinonasal structures are resected during ETSS, which raises concerns for nasal morbidity and patient-based outcome.

Objective

To perform a surgical outcome assessment by examining whether the extent of ETSS approaches affected patient-specific sinonasal quality of life as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22).

Methods

A single-center prospective cohort study of patients operated on by the same skull base team between 2012 and 2016. Patients with completed pre- and postoperative SNOT-22 were included. The primary outcome was SNOT-22 scores at preoperative, 0–1 month, 2–4 months, >5 months follow-up. Age, sex, tumor pathology, surgical procedure, and intraoperative cerebral spinal fluid leak repair were also obtained.

Results

Of the 249 ETSS performed, 148 patients (59%) had at least one completed SNOT-22; 45 (18%) met the inclusion criteria. Sinonasal quality of life based on SNOT-22 at the 0–1-month follow-up was significantly worse than the presurgical levels (p < 0.05). However, there was a return of SNOT-22 scores to preoperative levels at 2–4 months (p > 0.05), which was sustained at >5 months (p > 0.05). Factors such as the extent of ETSS, a previous nasal surgery, repair of an intraoperative cerebral spinal fluid leak, and the tumor pathology did not affect SNOT-22 scores at any follow-up intervals (p > 0.05).

Conclusion

Sinonasal quality of life worsened after ETSS at 0–1 month follow-up but returned to preoperative levels at 2–4 months and remained at postoperative levels >5 months. Analysis of these data will allow us to educate our patients that the anticipated nasal morbidity after ETSS is usually only transient and should be expected to recover to preoperative levels.

Development of the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire

BACKGROUND

The patients' perspective of health outcomes has become important input for assessing treatment effects. However, existing endoscopic endonasal surgery (EES) instruments are not fully aligned with the concept of health-related quality of life (HRQoL). A prospective cohort study was therefore conducted to develop a suitable quality-of-life tool to assess nasal morbidity after EES: the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q).

METHODS

The study included 300 patients: 207 with sinus pathology and 93 with anterior skull base pathology. The EES-Q was administered prior to surgery and postoperatively (2 weeks, 3 months, and 1 year). Psychometric instrument properties were tested and relevant health domains were formulated. Seventy-two items were generated by the conventional psychometric approach. An exploratory factor analysis was used to test construct validity. The optimal number of factors to retain was determined by using the eigenvalues-greater-than-1 rule and scree plot. Orthogonal varimax rotation was used to enhance interpretability. Internal consistency was assessed using the Cronbach α.

RESULTS

The factor analysis yielded a 3-factor solution, representing physical, psychological, and social functioning. The final version of the instrument consisted of 30 items with a high internal consistency (>0.80) for all 3 HRQoL domains.

CONCLUSIONS

The EES-Q is a comprehensive, multidimensional, disease-specific instrument. A distinguishing characteristic is that, apart from the physical and psychological domains, the EES-Q also encompasses a social domain. Understanding different HRQoL aspects in patients undergoing EES may help caregivers restore, improve, or preserve the patient's health through individualized care, which depends on identifying their specific needs.

Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery

OBJECTIVE The vascularized nasoseptal flap (NSF) has become the workhorse for skull base reconstruction during endoscopic endonasal surgery (EES) of the ventral skull base. Although infrequently reported, as with any vascularized flap the NSF may undergo ischemic necrosis and become a nidus for infection. The University of Pittsburgh Medical Center's experience with NSF was reviewed to determine the incidence of necrotic NSF in patients following EES and describe the clinical presentation, imaging characteristics, and risk factors associated with this complication. METHODS The electronic medical records of 1285 consecutive patients who underwent EES at the University of Pittsburgh Medical Center between January 2010 and December 2014 were retrospectively reviewed. From this first group, a list of all patients in whom NSF was used for reconstruction was generated and further refined to determine if the patient returned to the operating room and the cause of this reexploration. Patients were included in the final analysis if they underwent endoscopic reexploration for suspected CSF leak or meningitis. Those patients who returned to the operating room for staged surgery or hematoma were excluded. Two neurosurgeons and a neuroradiologist, who were blinded to each other's results, assessed the MRI characteristics of the included patients. RESULTS In total, 601 patients underwent NSF reconstruction during the study period, and 49 patients met the criteria for inclusion in the final analysis. On endoscopic exploration, 8 patients had a necrotic, nonviable NSF, while 41 patients had a viable NSF with a CSF leak. The group of patients with a necrotic, nonviable NSF was then compared with the group with viable NSF. All 8 patients with a necrotic NSF had clinical and laboratory evidence indicative of meningitis compared with 9 of 41 patients with a viable NSF (p < 0.001). Four patients with necrotic flaps developed epidural empyema compared with 2 of 41 patients in the viable NSF group (p = 0.02). The lack of NSF enhancement on MR (p < 0.001), prior surgery (p = 0.043), and the use of a fat graft (p = 0.004) were associated with necrotic NSF. CONCLUSIONS The signs of meningitis after EES in the absence of a clear CSF leak with the lack of NSF enhancement on MRI should raise the suspicion of necrotic NSF. These patients should undergo prompt exploration and debridement of nonviable tissue with revision of skull base reconstruction.

Preferences and Utilities for Health States after Treatment of Olfactory Groove Meningioma: Endoscopic versus Open

Objectives  The purpose of this study is to report health utility scores for patients with olfactory groove meningiomas (OGM) treated with either the standard transcranial approach, or the expanded endonasal endoscopic approach. Design  The time trade-off technique was used to derive health utility scores. Setting  Healthy individuals without skull base tumors were surveyed. Main Outcome Measures  Participants reviewed and rated scenarios describing treatment (endoscopic, open, stereotactic radiation, watchful waiting), remission, recurrence, and complications associated with the management of OGMs. Results  There were 51 participants. The endoscopic approach was associated with higher utility scores compared with an open craniotomy approach (0.88 vs. 0.74; p  < 0.001) and watchful waiting (0.88 vs.0.74; p  = 0.002). If recurrence occurred, revision endoscopic resection continued to have a higher utility score compared with revision open craniotomy (0.68; p  = 0.008). On multivariate analysis, older individuals were more likely to opt for watchful waiting ( p  = 0.001), whereas participants from higher income brackets were more likely to rate stereotactic radiosurgery with higher utility scores ( p  = 0.017). Conclusion  The endoscopic approach was associated with higher utility scores than craniotomy for primary and revision cases. The present utilities can be used for future cost-utility analyses.

Layered sellar reconstruction with avascular free grafts: Acceptable alternative to the nasoseptal flap for repair of low-volume intraoperative cerebrospinal fluid leak

BACKGROUND

Although the nasoseptal flap has become the method of choice for reconstruction of intraoperative cerebrospinal fluid (CSF) leak in endoscopic minimally invasive surgery of the skull base, layered avascular graft techniques, including allografts and middle turbinate mucosal autografts, may provide comparable reconstructive success with decreased nasal morbidity.

OBJECTIVE

To describe a method of reconstruction of intraoperative CSF leak in endoscopic surgery of the sella turcica and analyze its postoperative success rate and associated comorbidities.

METHODS

A retrospective review of expanded endonasal sellar tumor resections from 2008-2014 was performed, and cases of layered intraoperative skull base reconstruction with avascular free grafts were identified. Demographic factors and comorbidities that predisposed to reconstruction failure (obstructive sleep apnea, obesity) were determined. Reconstruction-related nasal complications were also identified. Postoperative CSF leak rate was determined, and statistical analysis was performed to identify predictive factors for reconstructive failure.

RESULTS

Seventy-three cases were identified. Layered closure with avascular free grafts was performed. There were five cases of postoperative CSF leak (6.85%). The mean follow-up was 19 months (range, 1-76 months). Intraoperative high-flow CSF leak was a significant predictor of reconstruction failure on univariate (odds ratio 22 [95% confidence interval, 2.26-214]; p = 0.008) and multivariate analysis (odds ratio 33.6 [95% confidence interval, 2.30-492]; p = 0.010). There were no significant differences in postoperative leak rates among bony overlay graft types. There were five patients (7.9%) who experienced persistent crusting after surgery. There were no significant differences in crusting rates between allografts and mucosal grafts. There were no postoperative mucoceles.

CONCLUSION

In cases of low-volume intraoperative CSF leak, layered skull base repair with avascular free grafts was an acceptable alternative to the nasoseptal flap, which may reduce prolonged sinonasal healing and donor-site morbidities.

Periodic olfactory assessment in patients undergoing skull base surgery with preservation of the olfactory strip

OBJECTIVES/HYPOTHESIS

Others have reported olfactory disturbances following endoscopic approaches to the skull base. However, there is a lack of consensus on the extent and duration of dysfunction. This study aimed to compare our results with previously published work and to validate the olfactory strip-sparing approach.

STUDY DESIGN

Prospective study to assess olfaction in 50 patients scheduled to undergo resection of skull base tumors via extended endoscopic approaches.

METHODS

Patients were divided into two groups. Group I had a nasoseptal flap (NSF), and group II included patients in whom rescue flaps were performed bilaterally. Olfactory outcomes were assessed using repeated University of Pennsylvania Smell Identification Test at baseline, 6 weeks, 3 months, and 6 months following surgery.

RESULTS

Ultimately, 42 patients (seven group I and 35 group II) were available for assessment. Scores for group I were lower than at baseline at 6 weeks postoperatively (30.71 ± 5.5 vs. 24.5 ± 5.4; P = .05). However, by the third postoperative month the scores had improved to a level that was not significantly different from baseline (29.0 ± 3.7; P = .5). At 6 months, the score was 30.0 ± 3.9. Patients in group II showed no difference between their baseline and 6-week scores (31.5 ± 5.3 vs. 29.7 ± 5.9; P = .16). Six months postoperatively, the score was significantly higher (33.78 ± 3.6; P = .04).

CONCLUSIONS

Expanded endoscopic approaches to skull base tumors involving reconstruction with an NSF are associated with a short-term negative impact on olfaction. Olfaction does not seem to be affected by the surgical resection of pituitary adenomas associated with rescue flaps. Identification of the olfactory epithelium and meticulous harvesting of the NSF are critical to preserve olfaction.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1970-1975, 2017.

Transient Exacerbation of Nasal Symptoms following Endoscopic Transsphenoidal Surgery for Pituitary Tumors: A Prospective Study

Object  Endoscopic transsphenoidal surgery is the commonest approach to pituitary tumors. One disadvantage of this approach is the development of early postoperative nasal symptoms. Our aim was to clarify the peak onset of these symptoms and their temporal evolution. Methods  The General Nasal Patient Inventory (GNPI) was administered to 56 patients undergoing endoscopic transsphenoidal surgery for pituitary tumors preoperatively and at 1 day, 3 days, 2 weeks, 3 months, and 6 to 12 months postoperatively. Most patients underwent surgery for pituitary adenomas ( N  = 49; 88%) and through a uninostril approach ( N  = 55; 98%). Total GNPI (0-135) and scores for the 45 individual components were compared. Results  GNPI scores peaked at 1 to 3 days postoperatively, with rapid reduction to baseline by 2 weeks and below baseline by 6 to 12 months postsurgery ( p  < 0.01). Of the 45 individual symptoms on the GNPI scale, 19 (42%) worsened transiently after surgery ( p  < 0.05). Functioning tumors had a higher GNPI scores at postoperative day 1 and 3 than nonfunctioning tumors, although their temporal evolution was the same ( p  < 0.05). Conclusions  Nasal morbidity following endoscopic transsphenoidal pituitary surgery is common, but transient, more so in the functioning subgroup. Nasal symptoms improve below baseline by 6 to 12 months, without the need for specific long-term postoperative interventions in the vast majority of patients.

Bolstering the Nasoseptal Flap Using Sphenoid Sinus Fat Packing: A Technical Case Report

BACKGROUND

Resection of extensive skull base lesions often necessitates relatively large dural openings and arachnoid, resulting in skull base defects with the potential for a postoperative cerebrospinal fluid leak. A nasoseptal flap (NSF) is a vascularized graft that has greatly diminished the incidence of cerebrospinal fluid leak. Annealing of flaps against the ventral skull base can be tenuous within the first few days after surgery. We report the use of sphenoid sinus fat packing as a buttress to support the nasoseptal flap during skull base reconstruction.

CASE DESCRIPTION

A 37-year-old man presented with pan-hypopituitarism, bitemporal hemianopsia, and imaging consistent with a craniopharyngioma. He underwent an endoscopic endonasal approach with resection of the planum and tuberculum sphenoidale for resection of this mass. An NSF was harvested, and a combination of suprasellar fat packing, tensor fasciae lata graft, and Porex plate along with the flap were used to reconstruct the skull base. Postoperatively, he precipitously experienced copious rhinorrhea necessitating surgical re-exploration. A redundant segment of the NSF had retracted into the sphenoid sinus, and was no longer supported against the ventral skull base. We repositioned the NSF and used sphenoid sinus fat packing to help support the graft against the ventral skull base. A postoperative computed tomographic scan demonstrated a clear delineation between the vascularized graft and the fat packing, confirming proper positioning of the flap.

CONCLUSION

Sphenoid sinus fat packing can be an important technical adjunct in bolstering the nasoseptal flap against the ventral skull base in the tenuous early perioperative period.

Free Mucosal Graft Reconstruction of the Septum after Nasoseptal Flap Harvest: A Novel Technique Using a Posterior Septal Free Mucosal Graft

Objectives The nasoseptal flap (NSF) has become the workhorse for reconstruction in endoscopic endonasal skull-base surgery. The NSF, though useful in reconstruction, may lead to significant donor site morbidity. Published techniques to reduce the donor site morbidity, free mucosal grafts, and septal rotational flaps have shown to reduce crusting and remucosalization times. We present a novel technique utilizing posterior septal mucosa as a free mucosal graft for reconstruction of the anterior septal donor site. The septal mucosal graft is taken from the mucosa overlying the posterior septectomy site of the endonasal approach to skull base tumors. Design Retrospective chart review. Setting Single tertiary academic medical center. Participants All patients who underwent endoscopic endonasal skull-base surgery between November 1, 2014 and August 30, 2015 with free mucosal graft reconstruction of the NSF donor site. Main Outcome Measures Postoperative graft success. Results Fifteen patients underwent septal reconstruction using a septal free mucosal graft. There was a 100% graft success rate with near complete remucosalization by 6 weeks postoperatively. Conclusions The posterior septal free mucosal graft is a simple, reliable method for reconstructing the NSF donor site. The advantages of this technique include utilization of native septal mucosal tissue and middle turbinate preservation.

Comprehensive Postoperative Management After Endoscopic Skull Base Surgery

To maximize outcomes from endoscopic skull base surgery, careful early postoperative management is critically important. Standardized postoperative regimens are lacking. The type of reconstruction and presence and type of cerebrospinal fluid leak dictate management. If a leak is encountered intraoperatively, patients should avoid maneuvers that increase intracranial pressures for at least 1 month. Early postoperative care focuses on minimizing and managing nasal crusting. This article reviews the evidence in the literature on postoperative management, complications, and quality of life after surgery, and outlines our experience in the management of patients after endoscopic skull base surgery.

Postoperative otorhinolaryngologic complications in transnasal endoscopic surgery to access the skull base

Introduction

The large increase in the number of transnasal endoscopic skull base surgeries is a consequence of greater knowledge of the anatomic region, the development of specific materials and instruments, and especially the use of the nasoseptal flap as a barrier between the sinus tract (contaminated cavity) and the subarachnoid space (sterile area), reducing the high risk of contamination.

Objective

To assess the otorhinolaryngologic complications in patients undergoing endoscopic surgery of the skull base, in which a nasoseptal flap was used.

Methods

This was a retrospective study that included patients who underwent endoscopic skull base surgery with creation of a nasoseptal flap, assessing for the presence of the following post-surgical complications: cerebrospinal fluid leak, meningitis, mucocele formation, nasal synechia, septal perforation (prior to posterior septectomy), internal nasal valve failure, epistaxis, and olfactory alterations.

Results

The study assessed 41 patients undergoing surgery. Of these, 35 had pituitary adenomas (macro- or micro-adenomas; sellar and suprasellar extension), three had meningiomas (two tuberculum sellae and one olfactory groove), two had craniopharyngiomas, and one had an intracranial abscess. The complications were cerebrospinal fluid leak (three patients; 7.3%), meningitis (three patients; 7.3%), nasal fossa synechia (eight patients; 19.5%), internal nasal valve failure (six patients; 14.6%), and complaints of worsening of the sense of smell (16 patients; 39%). The olfactory test showed anosmia or hyposmia in ten patients (24.3%). No patient had mucocele, epistaxis, or septal perforation.

Conclusion

The use of the nasoseptal flap has revolutionized endoscopic skull base surgery, making the procedures more effective and with lower morbidity compared to the traditional route. However, although mainly transient nasal morbidities were observed, in some cases, permanent hyposmia and anosmia resulted. An improvement in this technique is therefore necessary to provide a better quality of life for the patient, reducing potential complications.

Intranasal Volume Changes Caused by the Endoscopic Endonasal Transsphenoidal Approach and Their Effects on Nasal Functions

OBJECTIVE

We evaluated postoperative changes in nasal cavity volume and their effects on nasal function and symptoms after endoscopic endonasal transsphenoidal approach for antero-central skull base surgery.

STUDY DESIGN

Retrospective chart review at a tertiary referral center.

METHODS

We studied 92 patients who underwent binostril, four-hand, endoscopic endonasal transsphenoidal approach surgery using the bilateral modified nasoseptal rescue flap technique. Pre- and postoperative paranasal computed tomography and the Mimics® program were used to assess nasal cavity volume changes at three sections. We also performed several pre- and postoperative tests, including the Connecticut Chemosensory Clinical Research Center test, Cross-Cultural Smell Identification Test, Nasal Obstruction Symptoms Evaluation, and Sino-Nasal Outcome Test-20. In addition, a visual analog scale was used to record subjective symptoms. We compared these data with the pre- and postoperative nasal cavity volumes.

RESULTS

Three-dimensional, objective increases in nasal passage volumes were evident between the inferior and middle turbinates (p<0.001) and between the superior turbinate and choana (p = 0.006) postoperatively. However, these did not correlate with subjectively assessed symptoms (NOSE, SNOT-20 and VAS; all nasal cavity areas; p≥0.05) or olfactory dysfunction (CCCRC and CCSIT test; all nasal cavity areas; p≥0.05).

CONCLUSION

Skull base tumor surgery via an endoscopic endonasal transsphenoidal approach altered the patients' nasal anatomy, but the changes in nasal cavity volumes did not affect nasal function or symptoms. These results will help surgeons to appropriately expose the surgical field during an endoscopic endonasal transsphenoidal approach.

Anatomic Changes Caused by Endoscopic Endonasal Transsphenoidal Surgery and Their Effects on Nasal Functions

OBJECTIVE

We evaluated postoperative changes in nasal cavity dimensions and their effects on nasal functions and symptoms.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

We studied patients who underwent binostril, 4-hand endoscopic endonasal transsphenoidal approach surgery with the bilateral modified nasoseptal rescue flap technique. Pre- and postoperative paranasal computed tomography scans were used to assess nasal cavity dimensional changes at 4 levels. We also performed several pre- and postoperative tests, including the Connecticut Chemosensory Clinical Research Center test and the Cross-Cultural Smell Identification Test (n = 119) to evaluate olfactory functions. Also, the Nasal Obstruction Symptoms Evaluation, the Sino-Nasal Outcome Test-20, and a visual analog scale were used (n = 157) to record subjective symptoms. We compared these data with the pre- and postoperative nasal cavity dimensions.

RESULTS

Two-dimensional objective increases in nasal passage dimensions were evident postoperatively (all cross-sectional areas, P < .001, except choana and left inferior turbinate). However, these did not correlate with subjectively assessed symptoms (Nasal Obstruction Symptoms Evaluation, all cross-sectional areas, P ≥ .05, except right middle turbinate; Sino-Nasal Outcome Test-20, all cross-sectional areas, P ≥ .05) or olfactory dysfunction evaluated with the Connecticut Chemosensory Clinical Research Center test (all cross-sectional areas, P ≥ .05) or the Cross-Cultural Smell Identification Test (all cross-sectional areas, P ≥ .05).

CONCLUSION

Endoscopic endonasal transsphenoidal approach surgery altered the patients' nasal anatomy, but the changes in nasal cavity dimensions did not affect nasal functions and symptoms. These results will help surgeons to appropriately expose the surgical field during endoscopic endonasal transsphenoidal approach surgery.

Complications Related to the Endoscopic Endonasal Transsphenoidal Approach for Nonfunctioning Pituitary Macroadenomas in 300 Consecutive Patients

OBJECTIVE

To analyze complications of endoscopic transsphenoidal surgery (ETS) for nonfunctioning pituitary macroadenomas (NFPAs).

METHODS

A retrospective study of 300 NFPAs was performed. Complications and factors that could influence these complications were analyzed.

RESULTS

Visual and pituitary functions worsened in 2.4% and 13.7% of cases, respectively. Postoperative diabetes insipidus was permanent in 6.2% of cases. Postoperative meningitis occurred in 3.3% of patients. Meningitis was strongly associated with intraoperative cerebrospinal fluid (CSF) leaks (P = 0.01), postoperative CSF leaks (P = 0.0001), and operation times longer than 1 hour (P = 0.023). Detection of Staphylococcus aureus and preoperative treatment with mupirocin in the nostrils did not impact the occurrence of meningitis. Two patients with meningitis died (unique causes of death). Postoperative CSF leaks occurred in 2.7% of cases and were associated with intraoperative CSF leaks (P = 0.007) and permanent diabetes insipidus (P = 0.028). The rate of CSF leak decreased from 4% to 0.8% (P = 0.048) after we moved from a soft to hard reconstruction of the sella. The rate of postoperative epistaxis decreased from 6.7% to 1.25% after we stopped using monopolar coagulation (P = 0.013).

CONCLUSIONS

ETS permits a wide view, allowing good conditions for a satisfactory resection in the majority of NFPAs. Some pitfalls of endoscopy can lead to complications that improve with modification of the operative technique (i.e., CSF leak and postoperative epistaxis). This study confirms an acceptable rate of complications associated with ETS.

Endoscopic binostril versus transnasal transseptal microscopic pituitary surgery: Sinonasal quality of life and olfactory function

BACKGROUND

There have been few comparative studies on olfactory function and sinonasal-specific quality of life (QOL) after endoscopic or microscopic surgery using a transsphenoidal approach (TSA).

METHODS

A retrospective review of a prospectively collected database was performed. Thirty-five patients who underwent a transnasal endoscopic approach and 20 patients who underwent a transnasal transseptal microscopic approach for treatment of pituitary adenoma were evaluated. An anterior skull base (ASK) nasal inventory and a subjective visual analog scale (VAS) (0-100) for olfaction were evaluated before and at one and three months after surgery. A cross-cultural smell identification test (CC-SIT) and a butanol threshold test (BTT) were also measured before and three months after surgery.

RESULTS

There was no significant difference in subjective olfaction or CC-SIT or BTT score between the endoscopic and microscopic groups. The microscopic group (11.35 ± 3.67 and 9.72 ± 2.54, respectively) showed better ASK nasal inventory outcomes at one and three months after surgery compared with the endoscopic group (14.00 ± 4.85 and 11.70 ± 3.28, respectively; p = 0.029 and 0.036, respectively) especially in the subdomains of "nasal crusting" and "urge to blow nose."

CONCLUSION

Transnasal transseptal microscopic pituitary surgery confers a better early postoperative sinonasal QOL with a comparable olfactory outcome compared with the endoscopic approach. Although many believe that an endoscopic approach is less invasive, preservation of the sinonasal mucosa proves to be more important in terms of sinonasal QOL than use of an endoscope or microscope.

The endoscopic transoral approach to the craniovertebral junction: an anatomical study with a clinical example

OBJECTIVE

The microscopic transoral, endoscopic transnasal, and endoscopic transoral approaches are used alone and in combination for a variety of craniovertebral junction (CVJ) pathologies. The endoscopic transoral approach provides a more direct exposure that is not restricted by the nasal cavity, pterygoid plates, and palate while sparing the potential morbidities associated with extensive soft-tissue dissection, palatal splitting, or mandibulotomy. Concerns regarding the extent of visualization afforded by the endoscopic transoral approach may be limiting its widespread adoption.

METHODS

A dissection of 10 cadaver heads was undertaken. CT-based imaging guidance was used to measure the working corridor of the endoscopic transoral approach. Measurements were made relative to the palatal line. The built-in linear measurement tool was used to measure the superior and inferior extents of view. The superolateral extent was measured relative to the midline, as defined by the nasal process of the maxilla. The height of the clivus, odontoid tip, and superior aspect of the C-1 arch were also measured relative to the palatal line. A correlated clinical case is presented with video.

RESULTS

The CVJ was accessible in all cases. The superior extent of the approach was a mean 19.08 mm above the palatal line (range 11.1–27.7 mm). The superolateral extent relative to the midline was 15.45 mm on the right side (range 9.6–23.7 mm) and 16.70 mm on the left side (range 8.1–26.7 mm). The inferior extent was a mean 34.58 mm below the palatal line (range 22.2–41.6 mm). The mean distances were as follows: palatal line relative to the odontoid tip, 0.97 mm (range −4.9 to 3.7 mm); palatal line relative to the height of the clivus, 4.88 mm (range −1.5 to 7.3 mm); and palatal line relative to the C-1 arch, −2.75 mm (range −5.8 to 0 mm).

CONCLUSIONS

The endoscopic transoral approach can reliably access the CVJ. This approach avoids the dissections and morbidities associated with a palate-splitting technique (velopharyngeal insufficiency) and the expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach.

Endoscopic Modified Transseptal Transsphenoidal Approach for Maximal Preservation of Sinonasal Quality of Life and Olfaction

OBJECTIVE

Patients experience significant postoperative sinonasal symptoms for the first few months after endoscopic transnasal transsphenoidal approach (ETN-TSA) surgery. We modified this technique by bypassing the nasal mucosa and approaching through the septum bilaterally. In this study, we analyze whether these technical modifications, which we have termed the endoscopic modified transseptal transsphenoidal approach (EMTS-TSA), decrease postoperative sinonasal morbidity after endoscopic TSA.

METHODS

We retrospectively reviewed a prospectively collected database. Patients who underwent endoscopic TSA from December 2012 to June 2014 were included. Thirty patients underwent ETN-TSA, and 51 underwent EMTS-TSA. Sino-Nasal Outcome Test-20, anterior skull base nasal inventory, and visual analog scale (VAS) for subjective olfaction were evaluated before and 1 and 3 months after surgery. Cross Cultural Smell Identification Test also was measured before and 3 months after surgery.

RESULTS

There was a significant difference between the preoperative and 3-month VAS for olfaction in the ETN-TSA group (from 92.5 to 81.3; P = 0.002) but not the EMTS-TSA group (from 90.6 to 88.8; P = 0.403). There was no statistical difference in Sino-Nasal Outcome Test-20 or Cross-Cultural Smell Identification Test scores between 2 groups during follow-up. The EMTS-TSA group scored better than the ETN-TSA group in the anterior skull base nasal inventory subdomain ("nasal discharge," "urge to blow," and "trouble breading") 1 month postoperatively.

CONCLUSIONS

EMTS-TSA could preserve almost all nasal mucosa, including the septum and turbinates. EMTS-TSA may be useful for preserving early postoperative olfactory function and some sinonasal quality of life. We believe that EMTS-TSA is a good endoscopic pituitary surgery option.

Endoscopic Endonasal Reconstruction of Skull Base: Repair Protocol

Background Endoscopic endonasal skull base reconstructions have been associated with postoperative cerebrospinal fluid (CSF) leaks. Objective A repair protocol for endoscopic endonasal skull base reconstruction is presented with the objective of decreasing the overall leak rate. Methods A total of 180 endoscopic endonasal skull base reconstructions were reviewed. Reconstructions were classified I to IV according to the reconstruction method, determined by severity of intraoperatively encountered CSF leaks for types I to III, and planned preoperatively for type IVs, which required nasoseptal flap. Results A total of 11 patients(6%) had postoperative leaks: 0 in type I (0%), 2 in type II (5%), 7 in type III (18%), and 2 (4%) in type IV reconstruction. Type III leak rate was higher than all other reconstructions. Total 31 intraoperative and 16 postoperative lumbar drains were placed. More patients had lumbar drains placed postoperatively for type III and intraoperatively for type IV than all other groups. There were significant overall differences in postoperative CSF leaks and lumbar drain placement between the four reconstruction types. No patient with type III reconstruction and intraoperative lumbar drain had postoperative CSF leak. Conclusions A repair protocol for endoscopic endonasal reconstructions determined by intraoperative CSF leak and preoperative planning minimizes unnecessary repair materials and additional morbidity. Our experience leads to a routine prophylactic lumbar drain placement in all type III leak and reconstructions. We also favor the type III reconstruction for minor intraoperative leaks, and a more generous use of type IV reconstructions in expectation of significant intraoperative CSF leak. The option of rescue flap technique in type III leaks should be strongly considered.

Olfactory outcomes after endoscopic pituitary surgery with nasoseptal "rescue" flaps: electrocautery versus cold knife

BACKGROUND

Olfaction has been shown to have a large impact on patients' lives. Endoscopic pituitary surgery is associated with potentially significant damage to olfactory tissues. The objective of this study was to determine the effect of cauterization on olfactory function when performing endoscopic pituitary surgery with a nasoseptal "rescue" flap.

METHODS

A retrospective review was performed of prospectively collected data. Olfaction was the primary outcome and was measured using the subjective visual analog scale (VAS; 0-100) and Cross-Cultural Smell Identification Test (CC-SIT) before and 3 months after surgery. Significant olfactory deficit was defined as >20% loss compared with preoperative functions. Patients who underwent an endoscopic transsphenoidal approach with NSRFs for pituitary adenoma from June 2012 to March 2013 were included. Included patients were divided into two groups; group 1 underwent rescue flaps raised by monopolar cautery and group 2 underwent rescue flaps by cold knife.

RESULTS

Forty-nine patients were included in this study. There were 19 patients in group 1 and 30 patients in group 2. There was no significant difference in subjective olfactory change between the two groups (p = 0.386; group 1, 13.68 ± 17.7, versus group 2, 6.83 ± 8.25). However, 5 of 19 patients (26.3%) had significant olfactory loss in group 1 and 1 of 30 (3.3%) in group 2. This difference was statistically significant (p = 0.027). None of the patients showed a significant decrease in CC-SIT score.

CONCLUSION

Raising the rescue flap by cold knife could reduce the rate of hyposmia compared with using an electrocautery postoperatively.

Impact of nasoseptal flap elevation on sinonasal quality of life in endoscopic endonasal approach to pituitary adenomas

To evaluate the impact of nasoseptal flap (NSF) elevation on sinonasal quality of life (QOL) in patients with pituitary adenomas who underwent endoscopic endonasal trans-sphenoidal approach (EETSA), the data of 106 eligible patients were included from February 2011 to December 2014. The scores of Sinonasal Outcome Test (SNOT-22) Questionnaire were assessed in case (that received reconstruction with NSF) and control groups preoperatively as well as 1, 3, 6, and more than 12 months postoperatively. Nine most related sinonasal questions were evaluated separately (9Q). There were no significant inter-group differences in the mean SNOT-22, 9Q, and sense of taste/smell scores in preoperative and all postoperative assessments. Within each group, a significant improvement of SNOT-22 and 9Q scores were noted after 12 months of surgery compared to preoperative data. In the NSF group, comparison of the pre- and first postoperative evaluation revealed a significant deterioration in 9Q score (p = 0.007) and "sense of taste/smell" (p < 0.001) which both returned to baseline in the 3rd month. Patients who used nasal paper mask for more than 100 "hour-days" showed a better SNOT-22 scores at 1st (p = 0.04) and 3rd (p < 0.001) months after surgery. Patients with adrenocorticotropic hormone (ACTH) secretory adenomas showed significantly higher scores of SNOT-22 in all postoperative assessments compared to the others. Although nasal symptoms deteriorated at first postoperative month (compare to preoperative data) in the NSF group, no negative impacts on the sinonasal QOL was showed comparing to the control group. ACTH-secreting adenomas could be assumed as a risk factor for poorer sinonasal QOL in EETSA.

Hypernasality after using the endoscopic endonasal transsphenoidal approach for skull base tumors

OBJECTIVES/HYPOTHESIS

The increasing number of endoscopic endonasal transsphenoidal approaches (EETSA) has resulted in several sinonasal complications, including voice changes. Here, we compared preoperative and postoperative voice changes according to age.

METHODS

We retrospectively reviewed the medical records. Patients were divided into the following three groups according to age: ≤ 30 years, 31 to 60 years, and ≥ 60 years. Patients underwent preoperative voice evaluation using acoustic analysis, a nasometer, and the voice handicap index (VHI). A nasometer was used to measure the nasalance scores. The subjects read or repeated three speech stimuli. For each stimulus, mean nasalance scores were obtained and age dependence was analyzed. Repeat testing was performed 6 months postoperatively.

RESULTS

One hundred and seventy patients who underwent binostril four-hand EETSA with a bilateral modified rescue flap were included in this study. Mean nasalance scores for the oral passage, oronasal passage, and nasal passage--as well as mean jitter scores, shimmer scores, and VHI--were significantly increased in all of the EETSA patients (P < 0.05 for all). Mean nasalance scores for the nasal sentences were significantly increased in the ≤ 30 age group (all, P < 0.05). Scores for the oronasal passage and nasal passage were significantly increased in the 31 to 60 age group (all, P < 0.05). Scores for the oronasal passage, nasal passage, jitter, and shimmer were significantly increased in the > 60 age group (all, P < 0.05).

CONCLUSIONS

Endoscopic endonasal transsphenoidal approaches might contribute to voice changes. In addition, older age might produce hypernasality and roughness after EETSA. Patients who plan to undergo EETSA should be informed that their voice may change after the operation.

LEVEL OF EVIDENCE

4.

Nasal Deformities Following Nasoseptal Flap Reconstruction of Skull Base Defects

Objectives To identify the prevalence and risk factors for nasal deformities after endoscopic endonasal surgery (EES) of the skull base. Design Retrospective case series. Setting Tertiary referral academic center. Participants EES patients from January 2011 to October 2013. Main Outcome Measures Surgical approach, method of skull base reconstruction, and postoperative nasal deformities. Results Of 328 patients, 19 patients (5.8%) had nasal dorsum collapse, 3 (0.9%) with new septal perforations and 2 (0.6%) with septal deviations requiring surgical correction. Postoperative deformities were only found in the setting of nasoseptal flap reconstruction (p = 0.0001) and were most common in patients who had undergone an approach involving more than one anatomical subsite (p = 0.0021). Patients with nasal deformities were on average 6 years younger (p = 0.08) and were more likely to have a malignant pathology (p = 0.08). Conclusions All deformities were associated with use of a nasoseptal flap for reconstruction and were most common in combined approaches, suggesting that flap size may play a role in the development of nasal deformities. The mechanism of nasal dorsum collapse is unclear but does not appear to be related to septal cartilage necrosis. These findings warrant a prospective analysis to identify risk factors for postoperative nasal deformities and data for counseling of patients.

Panorama of reconstruction of skull base defects: from traditional open to endonasal endoscopic approaches, from free grafts to microvascular flaps

Introduction A substantial body of literature has been devoted to the distinct characteristics and surgical options to repair the skull base. However, the skull base is an anatomically challenging location that requires a three-dimensional reconstruction approach. Furthermore, advances in endoscopic skull base surgery encompass a wide range of surgical pathology, from benign tumors to sinonasal cancer. This has resulted in the creation of wide defects that yield a new challenge in skull base reconstruction. Progress in technology and imaging has made this approach an internationally accepted method to repair these defects.

Objectives Discuss historical developments and flaps available for skull base reconstruction.

Data Synthesis Free grafts in skull base reconstruction are a viable option in small defects and low-flow leaks. Vascularized flaps pose a distinct advantage in large defects and high-flow leaks. When open techniques are used, free flap reconstruction techniques are often necessary to repair large entry wound defects.

Conclusions Reconstruction of skull base defects requires a thorough knowledge of surgical anatomy, disease, and patient risk factors associated with high-flow cerebrospinal fluid leaks. Various reconstruction techniques are available, from free tissue grafting to vascularized flaps. Possible complications that can befall after these procedures need to be considered. Although endonasal techniques are being used with increasing frequency, open techniques are still necessary in selected cases.

Comparison of sinonasal quality of life and health status in patients undergoing microscopic and endoscopic transsphenoidal surgery for pituitary lesions: a prospective cohort study

OBJECT

Despite the widespread adoption of endoscopic transsphenoidal surgery for pituitary adenomas, the sinonasal quality of life (QOL) and health status in patients who have undergone this technique have not been compared with these findings in patients who have undergone the traditional direct uninostril microsurgical technique. In this study, the authors compared the sinonasal QOL and patient-reported health status after use of these 2 surgical techniques.

METHODS

The study design was a nonblinded prospective cohort study. Adult patients with sellar pathology and planned transsphenoidal surgery were screened at 4 pituitary centers in the US between October 2011 and August 2013. The primary end point of the study was postoperative patient-reported sinonasal QOL as measured by the Anterior Skull Base Nasal Inventory-12 (ASK Nasal-12). Supplementary end points included patient-reported health status estimated by the 8-Item Short Form Health Survey (SF-8) and EuroQol (EQ)-5D-5L instruments, and sinonasal complications. Patients were followed for 6 months after surgery.

RESULTS

A total of 301 patients were screened and 235 were enrolled in the study. Of these, 218 were analyzed (111 microsurgery patients, 107 endoscopic surgery patients). Demographic and tumor characteristics were similar between groups (p ≥ 0.12 for all comparisons). The most common complication in both groups was sinusitis (7% in the microsurgery group, 13% in the endoscopic surgery group; p = 0.15). Patients treated with the endoscopic technique were more likely to have postoperative nasal debridements (p < 0.001). The ASK Nasal-12 and SF-8 scores worsened substantially for both groups at 2 weeks after surgery, but then returned to baseline at 3 months. At 3 months after surgery, patients treated with endoscopy reported statistically better sinonasal QOL compared with patients treated using the microscopic technique (p = 0.02), but there were no significant differences at any of the other postoperative time points.

CONCLUSIONS

This is the first multicenter study to examine the effect of the transsphenoidal surgical technique on sinonasal QOL and health status. The study showed that surgical technique did not significantly impact these patient-reported measures when performed at high-volume centers. Clinical trial registration no.: NCT01504399 ( clinicaltrials.gov ).

Postoperative irrigation therapy after sinonasal tumor surgery

BACKGROUND

Sinonasal care after endoscopic tumor resection aims to manage crusting, edema, mucus, and a healing cavity. High-volume irrigations have proved beneficial in this setting. The addition of corticosteroid to the irrigation is used for chronic rhinosinusitis (CRS) in modifying the postsurgical inflammatory response; however, its effect in endoscopic sinonasal tumor resection is unknown. Saline alone versus combination saline and corticosteroid irrigations in postoperative nasal care of sinonasal tumor patients was assessed.

METHODS

A retrospective cohort of patients postendoscopic endonasal tumor resection was assessed. Patients used 240 mL of saline or 240 mL of saline with 1 mg of betamethasone daily. Nasal symptom scores (NSSs) and the 22-item Sino-Nasal Outcome test (SNOT-22) was recorded 3 months postoperatively. An endoscopic score was made of the area undergoing secondary healing at 3 months by two blinded assessors.

RESULTS

Fifty-nine patients were assessed (aged 50.1 ± 18.26 years; 36% female subjects). The groups were similar in number (saline n = 31), treatment, and surgical characteristics. The endoscopic scores did not differ between the groups at 3 months. NSS was lower in the saline group (1.0 [interquartile range {IQR}, 3] versus 7.0 [IQR, 9]; p = 0.03) and, similarly, for SNOT-22 (0.24 [IQR, 1] versus 1.09 [IQR, 1]; p = 0.01) compared with the saline with steroid group.

CONCLUSION

Although corticosteroid irrigations have become routine for managing inflammatory sinus disease at our center, their use after tumor surgery does not appear to be warranted. The inflammatory healing process after tumor surgery differs from CRS inflammation and may explain the observed findings.

Predictors of sinonasal quality of life and nasal morbidity after fully endoscopic transsphenoidal surgery

OBJECT

Despite the increasing application of endoscopic transsphenoidal surgery for pituitary lesions, the prognostic factors that are associated with sinonasal quality of life (QOL) and nasal morbidity are not well understood. The authors examine the predictors of sinonasal QOL and nasal morbidity in patients undergoing fully endoscopic transsphenoidal surgery.

METHODS

An exploratory post hoc analysis was conducted of patients who underwent endoscopic pituitary surgery and were enrolled in a prospective multicenter QOL study. End points of the study included patient-reported sinonasal QOL and objective nasal endoscopy findings. Multivariate models were developed to determine the patient and surgical factors that correlated with QOL at 2 weeks through 6 months after surgery.

RESULTS

This study is a retrospective review of a subgroup of patients studied in the clinical trial "Rhinological Outcomes in Endonasal Pituitary Surgery" (clinical trial no. NCT01504399, clinicaltrials.gov ). Data from 100 patients who underwent fully endoscopic transsphenoidal surgery were included. Predictors of a lower postoperative sinonasal QOL at 2 weeks were use of nasal splints (p = 0.039) and female sex at the trend level (p = 0.061); at 3 months, predictors of lower QOL were the presence of sinusitis (p = 0.025), advancing age (p = 0.044), and use of absorbable nasal packing (p = 0.014). Health status (multidimensional QOL) was also predictive at 2 weeks (p = 0.001) and 3 months (p < 0.001) and was the only significant predictor of sinonasal QOL at 6 months (p < 0.001). A Kaplan-Meier analysis was performed to study time to resolution of nasal crusting, mucopurulence, and synechia as observed during nasal endoscopy after surgery. The mean time (± SEM) to absence of nasal crusting was 16.3 ± 2.1 weeks, mucopurulence was 6.2 ± 1.1 weeks, and synechia was 4.4 ± 0.5 weeks. Use of absorbable nasal packing was associated with more severe mucopurulence.

CONCLUSIONS

Sinonasal QOL following endoscopic pituitary surgery reaches a nadir at 2 weeks and recovers by 3 months postoperatively. Use of absorbable packing and nasal splints, while used in a minority of patients, negatively correlates with early sinonasal QOL. Sinonasal QOL and overall health status are well correlated in the postoperative period, suggesting the important influence of sinonasal QOL on the patient experience.

Endoscopic transnasal interseptal approach for invasive clival tumors: development of an approach method regarding maximal preservation of the nasal anatomy

Asian people frequently show small noses, narrow nasal apertures, and congestive mucosa on the turbinates and septum. To reduce the risk of nasal morbidity with increased radicality for skull base tumors in these patients, we developed endoscopic transnasal interseptal approach (ETISA) in transsphenoidal surgery for invasive clival tumors (ICTs). Indication for ETISA is radical resection for tumors occupying deep ventral skull base regions, confined posterior to the level of the middle turbinates. After removing ethmoidal air cells, the middle turbinates are laterally deflected. A linear incision is made vertically on each side of the septal mucosa, which is separated from the bony septum as far as the sphenoid rostrum. The blades of an adjustable speculum are inserted submucosally, and the bony septum is temporarily displaced. The surgical pathway is widely maintained from the entrance to the deep surgical field without sacrificing the nasal mucosa and turbinates. Thirty-two consecutive patients with clival tumors (18 chordomas, 11 chondrosarcomas, 3 others) were treated. Bilateral middle turbinectomy was routinely performed in the initial 3 patients, but in only 4 of the remaining 29 (3 unilaterally, 1 bilaterally). Tumor was sufficiently resected in 29 patients (90.6%; gross total removal n = 25, subtotal resection n = 4). As complications, 6 patients showed mild and transient worsening of cranial nerve symptoms. Nasal complications arose in 3 patients, persisting > 3 months in 2 (5.7%). This approach allows fine bimanual handling and swift delivery of surgical equipment while reasonably preserving the nasal anatomy, which is useful in endoscopic transsphenoidal surgery for ICT.

Sinonasal outcomes following endoscopic anterior skull base surgery with nasoseptal flap reconstruction: a prospective study

OBJECTIVE

To assess nasal morbidity resulting from nasoseptal flap use in the repair of skull base defects in endoscopic anterior skull base surgery.

METHODS

Thirty-six patients awaiting endoscopic anterior skull base surgery were prospectively recruited. A nasoseptal flap was used for reconstruction in all cases. Patients were assessed pre-operatively and 90 days post-operatively via the Sino-Nasal Outcome Test 20 questionnaire and visual analogue scales for nasal obstruction, pain, secretions and smell; endoscopic examination findings and mucociliary clearance times were also recorded.

RESULTS

Sino-Nasal Outcome Test 20 questionnaire data and visual analogue scale scores for pain, smell and secretions showed no significant differences between pre- and post-operative outcomes, with visual analogue scale scores for nasal obstruction actually showing a significant improvement (p = 0.0007). A significant deterioration for both flap and non-flap sides was demonstrated post-operatively on endoscopic examination (p = 0.002 and p = 0.02 respectively).

CONCLUSION

Whilst elevation of a nasoseptal flap in endoscopic surgery of the anterior skull base engendered significant clinical deterioration on examination post-operatively, quality of life outcomes showed that no such deterioration was subjectively experienced by the patient. In fact, there was significant nasal airway improvement following nasoseptal flap reconstruction.

Changes Experienced in Quality of Life for Skull Base Surgical Patients: A Qualitative Case Study

Objective Skull base tumors are associated with quality of life (QOL) changes. A qualitative case-study approach may help better understand patients' experiences. Methods A total of 34 skull base surgery patients were selected into focus groups using a criterion-based maximum variation sampling strategy from a sampling frame of 138 patients. Eight groups were organized based on a factorial design of surgical approach (endoscopic/pen) and tumor location (anterior/central). Data were analyzed using a conceptual framework. Qualitative analysis was performed on focus group transcripts to identify major themes and determine if surgical approach or tumor location had differential effects on QOL. Concepts were quantitatively tallied from written workbooks. Results The 34 participants (19 men, 15 women; mean age: 48 years, standard deviation: 14 years) had mixed reactions to their diagnosis ranging from relief to fear. Participants reported physical and nonphysical changes in QOL with some variation in physical complaints by tumor location. Several major themes emerged from the analysis. Skull base tumors are associated with fear and frustration, loss of physical senses and self-identity, social isolation, and coping mechanisms. Conclusions Skull base surgery may impact patients' lives. Qualitative study of patient experiences can provide rich information to better understand this disease.

Comprehensive management of the paranasal sinuses in patients undergoing endoscopic endonasal skull base surgery

OBJECTIVE

The endonasal route often provides the most direct and safe approach to skull base pathology. In this article we review the literature with regard to management of the paranasal sinuses in the setting of skull base surgery.

METHODS

We describe our institutional experience and review the literature of concurrent management of the sinusitis in patients undergoing endoscopic skull base surgery.

RESULTS

Patients should be optimized preoperatively to ensure the endonasal route is a safe corridor to enter the intracranial cavity. Often the paranasal sinuses can be surgically addressed at the same time as endoscopic skull base surgery. We describe the technical details of management of the paranasal sinuses when addressing skull base pathology.

CONCLUSIONS

Careful management of the paranasal sinuses throughout the peri-operative course is paramount to optimizing sinonasal function and safety.

Advantages and limitations of endoscopic endonasal approaches to the skull base

BACKGROUND

The anatomy of the skull base is extremely complex with an abundance of critical neurovascular bundles and their corresponding foramina as well as the insertions and origins of multiple masticatory and craniocervical muscles. These anatomic intricacies increase the difficulty of surgery within this area.

METHODS

Advantages and disadvantages of endoscopic endonasal approaches (EEAs) based on the authors' sequential learning and experience are described.

RESULTS

EEAs offer the advantages of using preexistent air spaces that enable accessing various areas of the skull base, while avoiding external incisions or scars and obviating the need for the translocation of the maxillofacial skeleton. In addition, EEAs are well suited to preserve neurologic, visual, and masticatory functions as well as cosmesis. However, the sinonasal corridor must be expanded and optimized to access the skull base adequately, facilitate the reconstruction of the surgical defect, avoid sinonasal complications, and minimize sequelae. Important considerations can limit or indicate the approach, such as the nature of the pathology, including location, diagnosis, and vascularity; patient characteristics, including age and medical comorbidities; surgeon attributes, including training, experience, and expertise; the resultant need to reconstruct large skull base defects and feasible alternatives to do so; and institutional resources, including adjunctive services, an intensive care unit, and operating room equipment.

CONCLUSIONS

EEAs are important techniques in contemporary skull base surgery. Understanding the indications for and limitations of these approaches help to maximize outcomes.

Indications and limitations of the endoscopic endonasal approach for anterior cranial base meningiomas

OBJECTIVE

To describe the decision-making and the surgical strategy in the resection of anterior skullbase meningiomas.

METHODS

Details of the microsurgical and endoscopic approach to anterior skullbase meningiomas are presented.

RESULTS

Small and midsize olfactory groove, planum sphenoidale, and tuberculum sellae meningiomas can be removed via an endonasal endoscopic approach, an alternative option to the transcranial microsurgical approach. The choice of approach depends on tumor size and location, involvement of important neurovascular structures, and, most importantly, the surgeon's preference and experience. In my opinion, in most meningiomas, the endonasal approach has no advantage compared with the transcranial approach. Disadvantages of the endonasal approach are the discomfort after surgery and the prolonged recovery phase because of the nasal morbidity, which requires intensive nasal care. Compared with the eyebrow approach, the trauma to the nasal cavity, paranasal sinuses, and skull base is greater, and the risk of cerebrospinal fluid leak is higher.

CONCLUSION

For most skull base meningiomas, I usually prefer the endoscope-assisted microsurgical transcranial approach which combines the advantages of the operating microscope with the advantages of the endoscope. The endonasal approach is beneficial for small tumors located below or behind the chiasm.