Lateral nasal wall extension of the nasoseptal flap for skull-base and medial orbital wall defects

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Reconstruction of the Anterior Skull Base Using the Nasoseptal Flap: A Review

The nasoseptal flap is a workhorse reconstructive option for anterior skull base defects during endonasal surgery. This paper highlights the versatility of the nasoseptal flap. After providing a brief historical perspective, this review will focus on the relevant primary literature published in the last ten years. We will touch upon new applications of the flap, how the flap has been modified to expand its reach and robustness, and some of the current limitations. We will conclude by discussing what the future holds for improving upon the design and use of the nasoseptal flap in anterior skull base reconstruction.

Skull Base Reconstruction following Surgical Treatment of Sinonasal Malignancies

Skull base defects following resection of anterior cranial fossa and sinonasal tumors are not uncommon. Advances in endoscopic techniques have allowed for entirely endonasal resection and reconstruction of these tumors. This article discusses techniques in the evaluation and management of anterior skull base defects.

A Pedicled Posterior Septal-Nasal Floor Flap and a Novel Rescue Flap for Skull Base Reconstruction

OBJECTIVE

We devised a new surgical alternative to the conventional nasoseptal flap, a pedicled posterior septal-nasal floor flap that we named the Kegon flap. We evaluated the effectiveness of this flap for skull base reconstruction in patients with high-flow cerebrospinal fluid (CSF) leakage after sellar/parasellar tumor resection.

METHODS

The Kegon flap with a novel rescue flap was designed to preserve blood flow and mucosa anterior to the nasal septum and to avoid flap damage during surgery. We retrospectively evaluated postoperative flap perfusion with T1-weighted contrast-enhanced magnetic resonance imaging and characterized complications and wound healing in 5 patients who experienced high-flow CSF leakage after sellar/parasellar tumor resection requiring reconstruction.

RESULTS

Postoperative T1-weighted contrast-enhanced magnetic resonance imaging demonstrated good flap perfusion in all patients. The area reconstructed with the Kegon flap healed within the first month following surgery. No postoperative CSF leakage or nasal hemorrhage was observed. There was no perforation of the anterior nasal septum after surgery. The mucosal defect had completely epithelialized in all patients by 3 months after surgery. There were no instances of prolonged nasal crusting or any subjective decrease in olfactory function 3 months after surgery.

CONCLUSIONS

The use of a Kegon flap with a novel rescue flap was effective and helped preserve nasal structure and function in patients undergoing skull base reconstruction after sellar/parasellar tumor resection associated with high-flow CSF leakage.

Advances in vascularized flaps for skull base reconstruction

PURPOSE OF REVIEW

Advances in anterior skull base surgery have resulted in the increasing diversification of reconstructive techniques. New vascularized flaps have been suggested in the last years, some quite similar, whereas new uses and applications have been suggested for some vascularized flaps, which have already established their value over the last decades. In this article, we describe the developments in skull base reconstruction with vascularized flaps and analyse the international experience in the use of vascularized flaps published with a focus on the last 18 months.

RECENT FINDINGS

Over the past 18 months, a number of novel or modified vascularized intranasal flaps have been described, focusing on reconstruction of larger defects, the medial orbital wall, the anterior skull base (septal flip-flap) and dissection of the nasoseptal flap from the SPA foramen. Extranasal vascularized flaps, which have been around for a long time, still have their rightful place in skull base reconstruction and have recently been adjusted for endoscopic use.

SUMMARY

We present an overview of the latest developments in vascularized flaps (intranasal and extranasal), their new implications, their modifications and complications or predictions of viability.

Surgery around the Orbit: How to Select an Approach

Orbital region pathologies may be safely and effectively treated through a various number of approaches. As the concept of "outcome" and minimally invasive surgery keeps gaining popularity in neurosurgery, these approaches-each with specific indications and limitations-together provide the best surgical options.

Endoscopic Endonasal Approach for Intra- and Extraconal Orbital Pathologies

Endoscopic endonasal approaches offer an important alternative in the management of posterior inferomedial orbital pathology. Beginning with endoscopic orbital decompressions for Graves' disease, the endonasal corridor for the management of intra- and extraconal pathologies has continued to evolve. Endonasal removal of orbital cavernous hemangiomas is well described in the literature; however, many other benign and malignant pathologies of the medial orbit can be accessed through this approach. Advantages of the endonasal approach include improved visualization and decreased manipulation of orbital contents in the medial and posterior orbit. Additionally, for tumors that extend from the paranasal sinuses into the orbit, this corridor may be ideal for concurrent management. The current literature for this approach will be reviewed including the oncologic results, complications, limitations, and reconstructive needs along with pertinent anatomy. In addition, data from our own institution will be reviewed.