How to avoid mucocele formation under pedicled nasoseptal flap

Pedicled nasal flaps in transnasal endoscopic surgery: review of indications and surgical techniques

At present an exclusive endoscopic endonasal approach is sufficient in the majority of cases to treat pathologies involving the sinonasal compartment and the surrounding anatomical subsites (e.g. orbit, ventral skull base, upper parapharyngeal space, etc.) with the advantage of minimising surgical invasiveness. In this context, nasal vascularised local flaps are widely employed because they represent a more effective option for reconstruction or preservation of noble/vital structures compared to grafts. On the other hand, the surgical extension and morbidity are minimised compared to regional or free flaps. Several nasal local flaps have been described in the literature: the aim of this review is to examine their applications, characteristics, indications, success rates and morbidities. Different nasal flaps based on single or multiple pedicles have been described; the choice between them is based on different factors such as the flap’s shape and dimension, localisation of the pedicle’s origin, width of rotation angle, previous surgeries which could compromise vascularisation, and surgical experience, in addition to the position and dimension of the area which must be resurfaced.

Endoscopic endonasal cyst fenestration into the sphenoid sinus using the mucosa coupling method for symptomatic Rathke's cleft cyst: a novel method for maintaining cyst drainage to prevent recurrence

OBJECTIVE

Rathke's cleft cyst (RCC) is a benign cystic lesion with a relatively high incidence of local recurrence that occasionally requires repeat surgery. To prevent recurrence, simple cyst fenestration and drainage of the cyst contents to the sphenoid sinus is recommended, but it occasionally recurs. The authors postulated that obstruction of fenestration is a main cause of recurrence, and they developed a method, named the "mucosa coupling method (MC method)," that maintains persistent drainage. In this method, the RCC epithelium and the mucosa of the sphenoid sinus are connected, which promotes re-epithelialization between the two epithelia, maintaining persistent drainage. The outcome of this method was compared with that of conventional cyst fenestration.

METHODS

In a consecutive series of 40 patients with RCC, the surgical strategy was changed during the study period: from December 2009 to September 2014 (the conventional period), 24 patients were scheduled to be treated using the conventional fenestration method, whereas from September 2014 to September 2017 (the MC period), 16 patients were scheduled to be treated using the MC method. However, because of an intraoperative CSF leak, the fenestration was closed during surgery in 3 patients in the conventional period and 2 in the MC period; therefore, these 5 patients were excluded from the analysis. Twenty-one patients treated with the conventional fenestration method (conventional group) and 14 patients treated with the MC method (MC group) were analyzed. All patients regularly underwent MRI after surgery to detect reaccumulation of cyst contents. The rate of reaccumulation with and without reoperation, visual outcomes, endocrinological outcomes, and postoperative complications were compared between these two groups.

RESULTS

The median follow-up period in all 35 patients was 48.0 months (range 1-96 months), 54.0 months (range 1-96 months) in the conventional group and 35.5 months (range 12-51 months) in the MC group. No reaccumulation was detected on MRI in the 14 patients in the MC group, whereas it was noted in 9 (42.9%) of 21 patients in the conventional group, and 2 of these 9 patients required repeat surgery. There were no significant differences in visual and endocrinological outcomes and complications between these two groups.

CONCLUSIONS

The MC method for RCC is effective for preventing obstruction of cyst fenestration, which contributes to preventing cyst reaccumulation. Furthermore, this method is equivalent to the conventional fenestration method in terms of visual and endocrinological outcomes and the complication rate.

Closure of Skull Base Defects after Endonasal Endoscopic Resection of Planum Sphenoidale and Tuberculum Sellae Meningiomas

Background

The expanded endoscopic endonasal transplanum transtuberculum approach allows tumor removal by minimally invasive procedures. A large dural and bone defect is created during the surgical procedure, increasing the risk of postoperative cerebrospinal fluid (CSF) leakage.

Objective

The aim of this study is to describe a surgical technique and complications observed in patients undergoing endonasal resection of planum sphenoidale and/or tuberculum sellae meningiomas.

Methods

A retrospective analysis was performed of patients with planum sphenoidale and/or tuberculum sellae meningiomas after expanded endoscopic endonasal resection between June 2013 and August 2018, in which autologous grafts, fascia lata inlay, and nasoseptal flap onlay were used for closure of skull base defects.

Results

Ten patients were included in the analysis. No cases of postoperative CSF leakages or meningitis were reported, whereas two patients evolved with postoperative infectious complications (fungal ball in right frontal sinus and brain abscess). The skull base defect created for resection measured, on average, 3.58 cm².

Conclusion

Our experience suggests that closure of skull base defects using combined fascia lata inlay and nasoseptal flap onlay is effective for preventing postoperative CSF leakage in resection of planum sphenoidale and/or tuberculum sellae meningiomas, and offers high reproducibility due to its low cost.

Modified Posterior Pedicle Middle Turbinate Flap: An Additional Option for Skull Base Resurfacing

OBJECTIVES/HYPOTHESIS

Although the Hadad-Bassagusteguy flap represents the first choice for middle and posterior skull base reconstruction and coverage of exposed bony areas, in some cases it is unavailable. The aim of this study is to describe, as an alternative option in selected cases, a modified posterior pedicle middle turbinate flap (mPPMTF) extended to the lacrimal area. Anatomical features, step-by-step harvesting technique, and surgical applications are presented.

STUDY DESIGN

Anatomic dissection study and case report.

METHODS

Four mPPMTFs were raised in two fresh-frozen cadaver heads. A study of the vascular supply and measurements of length, width, and area of the flap were performed. The ability of the flap to cover the ventral skull base, particularly the upper clivus area, was tested. A clinical case in which an mPPMTF was used for clivus resurfacing after osteoradionecrosis is reported.

RESULTS

The vascular supply of the mPPMTF was identified as the middle turbinate branch of the sphenopalatine artery. The flap had a mean length of 6.92 cm, mean maximum width of 1.08 cm, and mean total area of 5.33 cm² . The flap was able to reach the upper clivus, with a clival coverage ratio of 70.66%. In the clinical case, good surgical outcomes were observed, with accelerated re-epithelization without complications.

CONCLUSIONS

The mPPMTF represents an alternative to the Hadad-Bassagusteguy flap for posterior cranial fossa and nasopharynx resurfacing. The main drawbacks are its technically demanding and time-consuming harvesting.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E767-E774, 2021.

Anatomo-radiological study supporting the use of ipsilateral nasoseptal flap for the transpterygoid management of temporo-sphenoidal meningoceles. A review of 21 cases

OBJECTIVES

Surgical treatment of temporo-sphenoidal meningoceles involves the reduction of the meningocele, watertight closure and defect coverage with a nasoseptal flap (NSF). It can be performed contralaterally or ipsilaterally: in the latter situation, the pedicle of the flap must be dissected into the pterygopalatine fossa. The objective of this study was to evaluate the benefit of using an ipsilateral NSF in transpterygoid approaches for the management of temporo-sphenoidal meningoceles, compared to a contralateral NSF, based on a radiological study.

MATERIAL AND METHODS

Retrospective monocentric study of 21 cases, between 2002 and 2018. Measurement of the NSF lengths, and lengths needed to cover the defect were evaluated on the preoperative scanner. Early and later failure and complication rates were evaluated.

RESULTS

Seventeen cases of temporo-sphenoidal meningoceles with available CT scan were identified. The mean duration of follow up was 27.9 months [1-147]. Theoretical lengths of the ipsi and contralateral NSF were comparable: 71.4±7.8mm vs. 78.8±8mm, P=0.729. In 8 cases/18 (42%), the theoretical length of the contralateral NSF was not long enough to cover the defect beyond the V2 (mean lack of 8.87±6.6mm). In all cases, the theoretical length of the ipsilateral NSF was sufficient to cover the defect. In the case series, failure and complication rates were similar.

CONCLUSION

The use of an ipsilateral NSF for the transpterygoid management of temporo-sphenoidal meningoceles, although more complex, allows a better coverage of the defect, compared to the contralateral NSF, which is not long enough in 42% of cases.

Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex

BACKGROUND

Nowadays the endoscopic approach represents a useful alternative to traditional surgical approaches in the treatment of cholesterol granulomas (CGs) of the petrous apex (PA). Recently the nasoseptal flap (NSF) has been employed to permit long-term patency of drainage site. The purpose of this study is to report our experience with the NSF in the endoscopic management of CG and to analyze the advantages, limitations, and outcomes of the technique.

METHODS

A retrospective analysis was carried out on 10 patients affected by CG of the PA who had been treated endoscopically, using the NSF.

RESULTS

An endoscopic transpterygoid approach was used for 6 patients and the remaining 4 were treated using the transclival approach. A NSF was used in all 10 cases. In 6 cases the flap was ipsilateral to the lesion whereas in 4 it was contralateral. In 90% of our patients no evidence of disease was observed after a mean follow-up period of 35.7 months, with resolution of their symptoms. One patient presented a recurrence because of a technical error (inadequate placement of the flap in the cavity), and has been retreated endoscopically.

CONCLUSION

The pedicled NSF seems to be helpful in avoiding the concentric growth of the granulomatous cyst epithelium while assuring ventilation and drainage of the cyst. However, bigger studies with longer-term follow-up are needed to confirm these findings. Correct and meticulous placement of the flap inside the cystic cavity is the most critical issue for the success of the procedure.

Palatovaginal (pharyngeal) artery: clinical implication and surgical experience

The palatovaginal or pharyngeal artery is a small branch of the internal maxillary artery supplying the nasopharynx. Bleeding from this artery is exceptional and only one case of traumatic epistaxis from this artery has been reported previously. We report a case of a 66-year-old male presenting with right recurrent posterior epistaxis. Endoscopic dissection of the pterygopalatine fossa and direct visualization of the palatosphenoidal canal permitted to identify the origin of bleeding, and coagulation of the pharyngeal artery solved the epistaxis. Although rare, intractable posterior epistaxis may arise from the pharyngeal artery. The anatomical knowledge of this artery and of the palatosphenoidal canal is of outmost importance in endoscopic transpterygoid and nasopharyngeal procedures, to identify the vidian canal, evaluate nasopharyngeal cancer spread in the pterygopalatine fossa, reduce bleeding during surgery of the nasopharynx, and harvest adequately the pedicle of the nasoseptal flap.