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Naimi BR, Farquhar D, Duffy AN, Garvey EA, Kelly P, Kahn C, Doshi R, Shah R, Rabinowitz MR, Toskala E, Rosen M, Evans JJ, Nyquist GG. Predictors of Subjective Olfactory Dysfunction and Sinonasal Quality-of-Life After Endoscopic Transsphenoidal Pituitary Surgery. Am J Rhinol Allergy 2024:19458924241243123. [PMID: 38646739 DOI: 10.1177/19458924241243123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
BACKGROUND This is the largest study in North America investigating olfactory outcomes after pituitary surgery to date. OBJECTIVE Characterize factors associated with subjective olfactory dysfunction (OD) and worsened sinonasal quality-of-life (QOL) after endoscopic TSA. METHODS Patients undergoing primary TSA for secreting and non-secreting pituitary adenomas between 2017 and 2021 with pre- and post-operative SNOT-22 scores were included. Subjective OD was determined by the smell/taste dysfunction question on the SNOT-22 (smell-SNOT). RESULTS 159 patients with pre- and post-operative SNOT-22 scores were included. Average total SNOT-22 scores worsened from pre-operative (16.91 ± 16.91) to POM1 (25.15 ± 20.83, P < .001), with no difference from pre-operative (16.40 ± 15.88) to POM6 (16.27 ± 17.92, P = .936) or pre-operative (13.63 ± 13.54) to POM12 (12.60 ± 16.45, P = .651). Average smell-SNOT scores worsened from pre-operative (0.40 ± 1.27) to POM1 (2.09 ± 2.01, P < .001), and pre-operative (0.46 ± 1.29) to POM6 (1.13 ± 2.45, P = .002), with no difference from pre-operative (0.40 ± 1.07) to POM12 (0.71 ± 1.32, P = .100). Female gender had a 0.9-point (95% CI 0.1 to 1.6) P = .021, increase in smell-SNOT at POM1, resolving by POM6 (0.1 [-0.9 to 1.1], P = .800) and POM12 (0.0 [-1.0 to 0.9], P = .942). Septoplasty with tunnel approach had a 1.1 [0.2 to 2.0] out of 5-point (P = .023) increase in smell-SNOT at POM1, resolving by POM6 (0.2 [-1.1 to 1.6], P = .764) and POM12 (0.4 [-0.9 to 1.6], P = .567). Female gender had a 9.5 (4.0 to 15.1)-point (P = .001) increase in SNOT-22 scores at POM1, resolving by POM6 (3.4 [-3.0 to 9.8], P = .292) and POM12 (6.4 [-5.4 to 18.2], P = .276). Intra-operative CSF leak had an 8.6 [2.1 to 15.1]-point (P = .009) increase in SNOT-22 scores at POM1, resolving by POM6 (5.4 [-1.7 to 12.5], P = .135), and POM12 (1.1 [-12.9 to 15.1], P = .873). CONCLUSION Changes in subjective olfaction and sinonasal QOL after TSA may be associated with gender, operative approach, and intra-operative CSF leak, resolving 6-12 months post-operatively.
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Affiliation(s)
- Bita R Naimi
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Douglas Farquhar
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander N Duffy
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Emily A Garvey
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Patrick Kelly
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Chase Kahn
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Riyana Doshi
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Riya Shah
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mindy R Rabinowitz
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Elina Toskala
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Marc Rosen
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James J Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gurston G Nyquist
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Jolly K, Gupta KK, Egbuji O, Naik PP, Ahmed SK. Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil ®. Br J Neurosurg 2024; 38:498-502. [PMID: 33769186 DOI: 10.1080/02688697.2021.1905771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/25/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. MATERIALS AND METHODS All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. RESULTS A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. CONCLUSIONS We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.
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Affiliation(s)
- Karan Jolly
- Department of Otolaryngology, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Keshav Kumar Gupta
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ofuchi Egbuji
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paresh Pramod Naik
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shahzada Khuram Ahmed
- Department of Otolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Ilgaz HB, Urgun K, Yener U, Mut M, Liu JK, Yağmurlu K. Microsurgical anatomy of the olfactory filaments in the nasal mucosa. J Neurosurg 2024:1-9. [PMID: 38518287 DOI: 10.3171/2024.1.jns23920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 01/09/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE The aim of this study was to examine the distribution of olfactory filaments (OFs) in the nasal mucosa to facilitate preservation of olfactory function in endonasal approaches and preparation of a nasoseptal flap. METHODS One formalin-fixed and 9 fresh cadaveric silicone-injected specimens with 20 total sides were studied to measure the distance of the OFs to the anatomical landmarks and compare the OF presence in the nasal septum mucosa (NSM) and ethmoidal mucosa (EM). RESULTS The mean distance from the first to the last OF was 19.37 ± 2.16 mm in the NSM and 23.44 ± 5.42 mm in the EM. The NSM had a mean of 7.55 ± 1.31 OFs and the EM had 14.3 ± 1.78. Average OF lengths were measured at 6.44 ± 1.48 (range 3.75-12.40) mm in the NSM and 8.05 ± 1.76 (range 4.14-13.20) mm in the EM. The mean values of the EM measurements were compared with those of the NSM; the number of OFs, the distance between the first and last OF, the average OF length, and the number of OFs between anterior and posterior ethmoidal arteries in the NSM were significantly less (p < 0.05) than those in the EM. The distance between the first OF to the nasal bone on the NSM was greater than on the EM. CONCLUSIONS Compared with the EM, the OFs are significantly fewer in number and smaller in size in the NSM. The uppermost edge of the nasoseptal flap incision in the NSM might be safer to start below 12 mm from the cribriform plate for OF protection.
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Affiliation(s)
- Hasan Barış Ilgaz
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
- 2Department of Anatomy, Hacettepe Medical School, Ankara, Turkey
| | - Kamran Urgun
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ulaş Yener
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Melike Mut
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - James K Liu
- 3Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
- 4Skull Base Institute of New Jersey, Neurosurgeons of New Jersey, NYU Langone Neurosurgery Network, Livingston, New Jersey
- 5Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Kaan Yağmurlu
- 6Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Kraimer K, Geltzeiler M. Skull Base Reconstruction by Subsite after Sinonasal Malignancy Resection. Cancers (Basel) 2024; 16:242. [PMID: 38254733 PMCID: PMC10813932 DOI: 10.3390/cancers16020242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Reconstruction after the resection of sinonasal malignancies is complex and primarily dependent on the defect size and location. While the reconstructive paradigm for sellar mass resection is well delineated, the challenges associated with reconstruction after sinonasal malignancy resection are less well described. This narrative review will address the goals of reconstruction after both endonasal endoscopic and open sinonasal malignancy resection and reconstructive options specific to these subsites. The goals of reconstruction include repairing cerebrospinal fluid leaks, restoring sinonasal function, providing a nasal airway, and optimizing the patient's quality of life. These goals are often complicated by the anatomic nuances of each involved sinus. In this review, we will discuss the methods of reconstruction specific to each sinonasal subsite and describe the factors that guide choosing the optimal reconstructive technique.
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Affiliation(s)
| | - Mathew Geltzeiler
- Department of Otolaryngology—Head and Neck Surgery, Oregon Health & Science University, Portland, OR 97239, USA
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Craig JR, Kim M, Spielman DB, Overdevest J, Ghanem T, Gudis DA. Nasoseptal Flap to Repair Large Maxillary Sinus Floor Defects. Laryngoscope 2024; 134:87-91. [PMID: 37159108 DOI: 10.1002/lary.30741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/09/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023]
Abstract
This case highlights the successful use of a large nasoseptal flap to repair a large maxillary sinus floor defect. Surgeons can therefore rely on this flap for repairing maxillary sinus floor defects of most sizes and locations. Laryngoscope, 134:87-91, 2024.
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Affiliation(s)
- John R Craig
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Matthew Kim
- Department of Otolaryngology-Head and Neck Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Daniel B Spielman
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Jonathan Overdevest
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Tamer Ghanem
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Werner MT, Yeoh D, Fastenberg JH, Chaskes MB, Pollack AZ, Boockvar JA, Langer DJ, D’Amico RS, Ellis JA, Miles BA, Tong CCL. Reconstruction of the Anterior Skull Base Using the Nasoseptal Flap: A Review. Cancers (Basel) 2023; 16:169. [PMID: 38201596 PMCID: PMC10778443 DOI: 10.3390/cancers16010169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/17/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
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.
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Affiliation(s)
- Michael T. Werner
- Department of Otolaryngology-Head & Neck Surgery, Northwell Health System, New York, NY 11042, USA; (M.T.W.); (D.Y.); (J.H.F.); (M.B.C.); (A.Z.P.); (B.A.M.)
| | - Desmond Yeoh
- Department of Otolaryngology-Head & Neck Surgery, Northwell Health System, New York, NY 11042, USA; (M.T.W.); (D.Y.); (J.H.F.); (M.B.C.); (A.Z.P.); (B.A.M.)
| | - Judd H. Fastenberg
- Department of Otolaryngology-Head & Neck Surgery, Northwell Health System, New York, NY 11042, USA; (M.T.W.); (D.Y.); (J.H.F.); (M.B.C.); (A.Z.P.); (B.A.M.)
| | - Mark B. Chaskes
- Department of Otolaryngology-Head & Neck Surgery, Northwell Health System, New York, NY 11042, USA; (M.T.W.); (D.Y.); (J.H.F.); (M.B.C.); (A.Z.P.); (B.A.M.)
| | - Aron Z. Pollack
- Department of Otolaryngology-Head & Neck Surgery, Northwell Health System, New York, NY 11042, USA; (M.T.W.); (D.Y.); (J.H.F.); (M.B.C.); (A.Z.P.); (B.A.M.)
| | - John A. Boockvar
- Department of Neurosurgery, Northwell Health System, New York, NY 11042, USA; (J.A.B.); (D.J.L.); (R.S.D.); (J.A.E.)
| | - David J. Langer
- Department of Neurosurgery, Northwell Health System, New York, NY 11042, USA; (J.A.B.); (D.J.L.); (R.S.D.); (J.A.E.)
| | - Randy S. D’Amico
- Department of Neurosurgery, Northwell Health System, New York, NY 11042, USA; (J.A.B.); (D.J.L.); (R.S.D.); (J.A.E.)
| | - Jason A. Ellis
- Department of Neurosurgery, Northwell Health System, New York, NY 11042, USA; (J.A.B.); (D.J.L.); (R.S.D.); (J.A.E.)
| | - Brett A. Miles
- Department of Otolaryngology-Head & Neck Surgery, Northwell Health System, New York, NY 11042, USA; (M.T.W.); (D.Y.); (J.H.F.); (M.B.C.); (A.Z.P.); (B.A.M.)
| | - Charles C. L. Tong
- Department of Otolaryngology-Head & Neck Surgery, Northwell Health System, New York, NY 11042, USA; (M.T.W.); (D.Y.); (J.H.F.); (M.B.C.); (A.Z.P.); (B.A.M.)
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Choi KY, Choi S, Jeong S, Won TB. Successful Endoscopic Transsphenoidal Approach Treatment of Sphenoid Sinus Organized Hematoma Causing Visual Deficit: A Case Report. Medicina (Kaunas) 2023; 59:1802. [PMID: 37893520 PMCID: PMC10608076 DOI: 10.3390/medicina59101802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/20/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023]
Abstract
Background: Organized hematoma in the sphenoid sinus is rare, but serious complications, such as visual deficits, can occur. Three such case reports have been published previously in the literature; however, none have achieved complete recovery of the vision. Case presentation: A 69-year-old male patient was referred to the ear, nose, and throat department with an expansile soft tissue mass filling the right sphenoid sinus and blurry vision in his right eye. Complete mass removal was achieved by a wide opening of the sphenoid sinus via an endoscopic transsphenoidal approach, followed by cauterization of the feeding artery and coverage by a nasoseptal flap. The patient's vision was restored after the operation, and he declared no visual symptoms until the latest follow-up (one year after the surgery). Conclusions: Complete excision with an endoscopic endonasal transsphenoidal approach can restore visual deterioration caused by a sphenoid sinus organized hematoma.
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Affiliation(s)
- Kyu Young Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea; (K.Y.C.); (S.C.)
| | - Sun Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea; (K.Y.C.); (S.C.)
| | - Suji Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Tae-Bin Won
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
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Takabayashi K, Iwama J, Takizawa K. Spontaneous Cerebrospinal Fluid Leakage at the Clivus: Minimally Invasive Surgery Without External Autograft Harvesting. Cureus 2023; 15:e48009. [PMID: 38034190 PMCID: PMC10687347 DOI: 10.7759/cureus.48009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Spontaneous cerebrospinal fluid (CSF) leakage at the clivus is rare. In previous reports, reconstructive materials used to treat such leakage were typically autografts. Considering the pathology, rigid reconstruction is preferred. We here describe a case of spontaneous CSF leakage at the clivus with multiple bony defects. In this case, in addition to using artificial material instead of autografts, such as fat or fascia, that require additional extranasal invasive harvesting site, a rigid material layer of septal cartilage and bone was also used, enabling more stable multilayer reconstruction. One month postoperatively, computed tomography revealed that the bony defect at the clivus had been well reconstructed. All nasal structures were preserved, and the nasoseptal flap was well engrafted. At eight months post-surgery, the patient remained in good condition. This method allows minimally invasive repair of the leaking clivus, according to the underlying pathophysiology.
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Affiliation(s)
- Kosuke Takabayashi
- Otorhinolaryngology, Japanese Red Cross Asahikawa Hospital, Asahikawa, JPN
- Otorhinolaryngology, Sapporo Medical University School of Medicine, Sapporo, JPN
| | - Junya Iwama
- Neurosurgery, Sassa General Hospital, Nishitokyo, JPN
- Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, JPN
| | - Katsumi Takizawa
- Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, JPN
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Lee YH, Lee SH, Seo MY. Delayed nasoseptal flap reuse in patients with revision endoscopic endonasal anterior skull base surgery. Clin Case Rep 2023; 11:e8001. [PMID: 37780926 PMCID: PMC10533374 DOI: 10.1002/ccr3.8001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023] Open
Abstract
The reuse of the nasoseptal flap represents a favorable option for skull base reconstruction in revision endoscopic anterior skull base surgery. This study demonstrated that a detached nasoseptal flap can remain viable for several days even if not immediately reattached.
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Affiliation(s)
- Ye Hwan Lee
- Department of Otorhinolaryngology – Head and Neck Surgery, Division of Rhinology and Sleep MedicineKorea University College of Medicine, Korea University Ansan HospitalAnsanSouth Korea
| | - Seung Hoon Lee
- Department of Otorhinolaryngology – Head and Neck Surgery, Division of Rhinology and Sleep MedicineKorea University College of Medicine, Korea University Ansan HospitalAnsanSouth Korea
| | - Min Young Seo
- Department of Otorhinolaryngology – Head and Neck Surgery, Division of Rhinology and Sleep MedicineKorea University College of Medicine, Korea University Ansan HospitalAnsanSouth Korea
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Joshua SP, Sundar SS, Viswam V, Panikar D. Modified Nasoseptal Flap Technique to Prevent the Recurrence of Rathke's Cleft Cyst. Neurol India 2023; 71:678-681. [PMID: 37635497 DOI: 10.4103/0028-3886.383837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Background Rathke's cleft cysts (RCCs) are benign epithelial lesions arising from the Rathke's pouch remnants that fail to regress during embryogenesis. Some RCCs become symptomatic and require treatment. Cyst fenestration and drainage of its contents is the preferred procedure to treat symptomatic cases but carries a risk of recurrence. We propose the use of a novel modified nasoseptal flap technique to partially line the cyst wall to avoid recurrence. Methods This was a prospective, observational study that included all RCC patients admitted to the Department of Neurosurgery, Aster Medcity, from April 2015 to May 2018. The modified nasoseptal flap technique was performed in all patients. They underwent preoperative and postoperative ophthalmological, endocrine, endoscopic, and MRI evaluations to look for recurrence. Results Ten patients underwent the modified nasoseptal flap technique. The median follow-up was 36 months. Postoperatively, all patients were relieved from headaches. Moreover, their visual fields and pituitary functions normalized. None of the patients developed recurrence of RCC on follow-up brain MRI. On endoscopic examination, all patients had retained patency of the fenestra. The longest follow-up was 72 months. Conclusions The modified nasoseptal flap technique maintains patency and avoids recurrence of RCCs on long-term follow-up.
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Affiliation(s)
- Shejoy P Joshua
- Department of Neurosurgery, Aster Medcity, Kochi, Kerala, India
| | - S Shyam Sundar
- Department of Neurosurgery, Aster Medcity, Kochi, Kerala, India
| | - Vineeth Viswam
- Department of Otorhinolaryngology, Aster Medcity, Kochi, Kerala, India
| | - Dilip Panikar
- Department of Neurosurgery, Aster Medcity, Kochi, Kerala, India
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El-Sayed IH, Jiam NT, Theodosopoulos PV, McDermott MW, Gurrola JG, Aghi MK. Formal Closure of Endoscopic Endonasal Skull Base Defects With a "Bow Tie" Tri-Layer Graft. Laryngoscope 2023; 133:1568-1575. [PMID: 36169353 DOI: 10.1002/lary.30407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Risk factors for a postoperative cerebrospinal fluid leak (CSF) after surgery include an intraoperative high flow of CSF, elevated body mass index, defect size, and defect site. In our prior series, a high postoperative CSF leak rate for tumors of the central skull base (planum, sella, and clivus) appeared to be due to graft migration. We changed our closure technique from a single layer of collagen +/- fat graft to a novel graft, termed a "Bow tie" (a tri-layer fat graft with two pieces of collagen matrix), and report our results in this study. METHODS Retrospective temporal epoch study of a single otolaryngologist's experience of closing skull base defects in our skull base center from 2005 to 2017. RESULTS One hundred and forty-nine patients met inclusion criteria in two time periods, pre- and post-introduction of the Bow tie technique. In epoch I, from 2005 to 2013, 79 patients had reconstruction with a single layer of dural graft (25 had additional free fat graft). In epoch II, from 2014 to 2017, 70 patients had reconstruction with the Bow tie. RESULTS CSF leak rates were 8.7% overall: 15.2% in epoch I and 1.4% in epoch II (p = 0.01). After controlling the procedure, defects with a size greater than 2 cm had a 5.7 greater likelihood of failure. Epoch II had a lower incidence of major complications. CONCLUSION Using a single surgeon's experience, the multilayer Bow tie has a significant reduction in postoperative CSF leak and associated major complications for defects of the central skull base. LEVEL OF EVIDENCE 3 Laryngoscope, 133:1568-1575, 2023.
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Affiliation(s)
- Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Nicole T Jiam
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, U.S.A
- Miami Neuroscience Institute, Baptist Health, Miami, Florida, U.S.A
| | - Jose G Gurrola
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, U.S.A
| | - Manish K Aghi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, U.S.A
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Strober WA, Valappil B, Snyderman CH. Impact of Reverse Septal Flap on Morbidity of Nasoseptal Flap Reconstruction of Skull Base Defects. Am J Rhinol Allergy 2023:19458924231166801. [PMID: 36991310 DOI: 10.1177/19458924231166801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND The workhorse for endonasal reconstruction of skull base defects is the posteriorly-based nasoseptal flap (NSF). Postoperative nasal deformities and decreased olfaction are potential complications of NSF. The reverse septal flap (RSF) minimizes the donor site morbidity of the NSF by covering the exposed cartilage of the anterior septum. Currently, there are minimal data examining its effect on outcomes including nasal dorsum collapse and olfaction. OBJECTIVE Our study aims to clarify whether the RSF should be utilized when the option exists. METHODS Adult patients undergoing endoscopic endonasal approach (EEA) surgery of the skull base (transsellar/transplanum/transclival approaches) with NSF reconstruction were identified. Data from 2 separate cohorts, one retrospective and one prospective, were collected. Follow-up was at least 6 months. Patients were photographed preoperatively and postoperatively using standard rhinoplastic nasal views. Patients completed the University of Pennsylvania Smell Identification Test (UPSIT) and the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and postoperatively and were also queried regarding subjective changes in nasal appearance and plans for cosmetic surgery following EEA. RESULTS There were no statistically significant differences in the change in UPSIT and SNOT-22 scores between patients receiving RSF and other reconstructive groups (either NSF without RSF or no NSF). One of 25 patients who were reconstructed with an NSF with RSF reported a change in nasal appearance; none were considering reconstructive surgery. The proportion of patients reporting changes in appearance was significantly lower in the NSF with RSF group as compared to the NSF without RSF group (P = .012). CONCLUSION The use of an RSF to limit donor site morbidity of the NSF was shown to significantly decrease the proportion of patients who reported nasal deformities and did not show a significant difference in patient-reported sinonasal outcomes. Given these findings, RSF should be considered whenever an NSF is used for reconstruction.
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Affiliation(s)
- William A Strober
- 12317University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Benita Valappil
- Department of Otolaryngology, 12317University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Department of Otolaryngology, 12317University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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13
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Pool C, Abiri A, Kuan EC. Skull Base Reconstruction following Surgical Treatment of Sinonasal Malignancies. J Neurol Surg Rep 2023; 84:e17-e20. [PMID: 36741228 PMCID: PMC9894721 DOI: 10.1055/a-2009-8865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Christopher Pool
- Departments of Otolaryngology – Head and Neck Surgery, Kaiser Permanente Orange County, Anaheim, California, United States
| | - Arash Abiri
- Departments of Otolaryngology – Head and Neck Surgery and Neurological Surgery, University of California, Irvine, Orange, California, United States
| | - Edward C. Kuan
- Departments of Otolaryngology – Head and Neck Surgery and Neurological Surgery, University of California, Irvine, Orange, California, United States,Address for correspondence Edward C. Kuan, MD, MBA Department of Otolaryngology – Head and Neck Surgery, University of California – Irvine101 The City Drive South, Orange, CA 92868United States
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14
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Lai CCF, Chow SMW, Tong MCF. Endonasal Acoustic Doppler Sonography in Predicting the Survival of Nasoseptal Flap Following Previous Irradiation. Laryngoscope 2023; 133:244-247. [PMID: 35246992 DOI: 10.1002/lary.30095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/29/2022] [Accepted: 02/12/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Blood supply to the nasoseptal flap may be compromised in patients who had previous irradiation to the head and neck region, hence, affecting its viability. Here, we evaluate the role of an endonasal acoustic Doppler sonography in predicting the survival of the nasoseptal flap in this group of patients. STUDY DESIGN Retrospective cohort. METHODS Retrospective review of patients with previous irradiation to the head and neck region who had undergone endoscopic endonasal surgeries requiring nasoseptal flap as reconstruction. Survival rates of nasoseptal flap were compared between groups where endonasal Doppler was used. RESULTS A total of 28 patients were identified with previous irradiation to the head and neck region who had undergone endoscopic endonasal surgeries requiring nasoseptal flap as reconstruction. The overall survival rate of nasoseptal flap is 67.8% (19 out of 28). Endonasal acoustic Doppler was used in 17 of these patients, of which 13 patients had a positive signal. The flap survival rate in the Doppler-positive group compared to the non-Doppler group was significantly better at 100% vs 45.4% (P = .003). Among those where the endonasal Doppler was used, the flap survival rate with a negative doppler signal was significantly worse at 25%, compared with 100% flap survival in those with positive doppler signal (P = .006). The positive predictive value of a positive endonasal Doppler signal with flap survival is 100%. CONCLUSION The use of endonasal acoustic Doppler may be useful in predicting the viability of nasoseptal flap in postirradiated patients who need a local mucosal flap coverage. LEVEL OF EVIDENCE 3 Laryngoscope, 133:244-247, 2023.
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Affiliation(s)
- Calvin Chee-Fung Lai
- Department of Otorhinolaryngology, Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong S.A.R
| | - Samuel Man-Wai Chow
- Department of Otorhinolaryngology, Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong S.A.R
| | - Michael Chi-Fai Tong
- Department of Otorhinolaryngology, Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong S.A.R
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15
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Baussart B, Venier A, Jouinot A, Reuter G, Gaillard S. Closure strategy for endoscopic pituitary surgery: Experience from 3015 patients. Front Oncol 2023; 12:1067312. [PMID: 36686774 PMCID: PMC9846073 DOI: 10.3389/fonc.2022.1067312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Effective strategies are required to ensure optimal management of the crucial closure step in endoscopic pituitary surgery. Many surgical techniques have been reported but no significant consensus has been defined. Methods Between January 2006 and March 2022, 3015 adult patients with pituitary adenomas were operated on by a single expert neurosurgical team, using a mononostril endoscopic endonasal approach. Based of preoperative risk factors of and operative findings, a detailed closure strategy was used. Body mass index >40, sellar floor lysis, number of surgeries>2, large skull base destruction, prior radiotherapy were considered as preoperative risk factors for closure failure. All patients treated with an expanded endonasal approach were excluded. Results Patients were mostly women (F/M ratio: 1.4) with a median age of 50 (range: 18 -89). Intraoperative CSF leak requiring specific surgical management was observed in 319/3015 (10.6%) of patients. If intraoperative leak occurred, patients with predictive risk factors were managed using a Foley balloon catheter in case of sellar floor lysis or BMI>40 and a multilayer repair strategy with a vascularized nasoseptal flap in other cases. Postoperative CSF leak occurred in 29/3015 (1%) of patients, while meningitis occurred in 24/3015 (0.8%) of patients. In patients with intraoperative leak, closure management failed in 11/319 (3.4%) of cases. Conclusion Based on our significant 16-year experience, our surgical management is reliable and easy to follow. With a planned and stepwise strategy, the closure step can be optimized and tailored to each patient with a very low failure rate.
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Affiliation(s)
- Bertrand Baussart
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France,*Correspondence: Bertrand Baussart, ;
| | - Alice Venier
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Anne Jouinot
- Université Paris Cité, Institut Cochin, CNRS, INSERM, Paris, France
| | - Gilles Reuter
- Department of Neurosurgery, Centre Hospitalier Universitaire (CHU) de Liège, Bat B35, Domaine Universitaire du Sart-Tilman, Liège, Belgium
| | - Stephan Gaillard
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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16
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Wang K, Zhao G, Xian M, Song X, Wang P, Feng Y, Wu D, Wang C, Zhang L. Lateral pedicled nasoseptal flaps for bilateral frontal sinus inverted papillomas after endoscopic Draf III procedure. Int Forum Allergy Rhinol 2022. [PMID: 36458700 DOI: 10.1002/alr.23109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 10/17/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Kuiji Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China.,Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Guoqiang Zhao
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China.,Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Mu Xian
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Xiaohong Song
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Ping Wang
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Yuxin Feng
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Di Wu
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Chengshuo Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China.,Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Beijing, China.,Research Unit of Diagnosis and Treatment of Chronic Nasal Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China.,Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
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17
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Pinheiro-Neto C, Rowan NR, Celda MP, Mukherjee D, Gompel JJV, Choby G. Optimizing Quality of Life and Minimizing Morbidity through Nasal Preservation in Endoscopic Skull Base Surgery: A Contemporary Review. J Neurol Surg B Skull Base 2022; 83:602-610. [PMID: 36393878 PMCID: PMC9653292 DOI: 10.1055/s-0042-1749654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/21/2022] [Indexed: 10/15/2022] Open
Abstract
Introduction Endoscopic endonasal approaches (EEAs) are increasingly utilized for intracranial pathology. As opposed to sinonasal tumors, the nasal cavity is being used as a corridor to access these intracranial tumors but is not the site of primary surgical intent. Accordingly, there has been recent interest in preserving intranasal structures not directly involved by tumor and improving postoperative sinonasal quality of life (QOL). Objectives The aim of the study is to highlight recent advances in EEA techniques focused on improving sinonasal QOL including turbinate preservation, reducing the morbidity of reconstructive techniques, and the development of alternative minimally invasive EEA corridors. Methods The method of the study involves contemporary literature review and summary of implications for clinical practice. Results Nasoseptal flap (NSF) harvest is associated with significant morbidity including septal perforation, prolonged nasal crusting, and external nasal deformities. Various grafting and local rotational flaps have demonstrated the ability to significantly limit donor site morbidity. Free mucosal grafts have re-emerged as a reliable reconstructive option for sellar defects with an excellent sinonasal morbidity profile. Middle turbinate preservation is achievable in most EEA cases and has not been shown to cause postoperative obstructive sinusitis. Recently developed minimally invasive EEA techniques such as the superior ethmoidal approach have been described to better preserve intranasal structures while allowing intracranial access to resect skull base tumors and have shown promising sinonasal QOL results. Conclusion This contemporary review discusses balancing effective skull base reconstructive techniques with associated morbidity, the role of turbinate preservation in EEA, and the development of unique EEA techniques that allow for increased nasal structure preservation.
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Affiliation(s)
- Carlos Pinheiro-Neto
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Nicholas R. Rowan
- Department of Otolaryngology—Head & Neck Surgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Maria Peris Celda
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Debraj Mukherjee
- Department of Neurologic Surgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Jamie J. Van Gompel
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Garret Choby
- Department of Otolaryngology—Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
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18
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Alshareef M, Alroqi A, Albaharna H, Alsayed A, Alromaih S, Alrasheed AS, Ajlan A, Alsaleh S. Nasoseptal flap and rigid reconstruction in endoscopic endonasal skull base surgeries: The longitudinal experience of a single center. Ear Nose Throat J 2022:1455613221099483. [PMID: 35603535 DOI: 10.1177/01455613221099483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Recently, endoscopic endonasal approaches (EEA) have been used for skull base defect reconstruction surgeries. The nasoseptal flap (NSF), a vascular pedicled flap, was introduced to decrease postoperative cerebrospinal fluid (CSF) leakage. PURPOSES This study aimed to outline the authors' institutional experience using NSF and rigid implants in anterior skull base defect reconstruction surgeries following EEA. DESIGN A retrospective cohort review of patients who underwent NSF reconstruction following EEA in the Otorhinolaryngology and Neurosurgery Departments at King Saud University Medical City, Riyadh, Saudi Arabia, from January 2015 to May 2021, divided into 2 time periods according to the reconstruction technique. RESULT Out of the 106 patients who underwent EEA, 77 underwent NSF reconstruction. The majority had expanded EEA (94.8%). The mean age was 40.21 ± 17.7 years, and the female gender represented 61% of the sample. More than half of the sample underwent right NSF (57.1%). Meningioma was the most common diagnosis (45.5%). The clivus was the most frequent site of lesions (23.4%). The overall rate of postoperative CSF leakage and lumbar drainage (LD) insertion was 15.6% and 51.9%, respectively. The duration of LD was a median of four days. The overall failure rate was 13%, declining from 20% in the first period to 5.4% in the second period. Rigid implants were used significantly more in the first period than in the second period (67.5% versus 16.2%, P < 0.001). Meningitis, the highest postoperative complication, was reported in 6 patients (7.8%). One patient died three weeks postoperatively after massive nasal bleeding. No significant difference was found between either side of the NFS regarding the CSF leakage and failure rate. CONCLUSION In the authors' experience, there has been an overt decline in failure rates and complications of EEA over the last three years due to increased experience among surgeons and a standardization of reconstruction techniques. Minimal reconstruction may provide satisfactory results by decreasing the use of rigid implants. An endoscopic endonasal approach with an NSF for anterior skull base defect reconstruction is considered a safe procedure with no significant difference between the sides of the flap.
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Affiliation(s)
- Mohammad Alshareef
- Department of Otolaryngology-Head and Neck Surgery, Khamis Mushait General hospital - Khamis Mushait City, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Alroqi
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Hussain Albaharna
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, 48070Qatif Central Hospital - Qatif City, Saudi Arabia
| | - Ahmed Alsayed
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Saud Alromaih
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz S Alrasheed
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
| | - Abdulrazag Ajlan
- Department of Neurosurgery, 191082College of Medicine King Saud University, Riyadh, Saudi Arabia
| | - Saad Alsaleh
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, 191082King Saud University, Riyadh, Saudi Arabia
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19
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Obermeyer IP, Sterritt N, Haidar YM, Tjoa T, Kuan EC. Multilayered Closure of Oronasal and Oroantral Fistula Using Intranasal and Intraoral Flaps. Laryngoscope 2022; 132:2259-2261. [PMID: 35348210 DOI: 10.1002/lary.30111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 02/08/2022] [Accepted: 03/04/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Isaac P Obermeyer
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Naya Sterritt
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Yarah M Haidar
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Tjoson Tjoa
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A
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20
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Suzuki H, Yokoi M, Hagiwara S, Sasaki E, Kobayashi Y, Iwaki S, Nishikawa D, Beppu S, Terada H, Sawabe M, Hanai N. A Case of Salvage Maxillectomy for Recurrent Oral Cancer After Boron Neutron Capture Therapy During the COVID-19 Pandemic. Anticancer Res 2022; 42:1653-1657. [PMID: 35220265 DOI: 10.21873/anticanres.15642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND During the COVID-19 pandemic, pedicle flaps instead of free flap transfer were recommended for head and neck reconstruction to reduce infection risk. Boron neutron-capture therapy in Japan was clinically approved in 2020 as a salvage radiotherapy for recurrent head and neck cancer following chemoradiotherapy. The efficacy and safety of salvage surgery following boron neutron-capture therapy remain unclear. CASE REPORT We describe a 57-year-old male with crT4aN0M0 oral cancer after three different forms of radiotherapy including boron neutron-capture therapy, treated by salvage partial maxillectomy with both buccal fat pad and nasoseptal flaps. His postsurgical course was successful, without tracheostomy, and he had no Clavien- Dindo grade 3 or 4 complications. The pathological diagnosis was T4a squamous cell carcinoma with a negative surgical margin. No recurrence or metastasis had occurred at 113 days postoperatively. No opioid consumption was needed postoperatively. CONCLUSION Pathological negative margins were achieved in this case and there were no severe complications. Further accrual of cases salvage surgery following boron neutron-capture therapy is required to clarify treatment strategies for recurrent head and neck cancer.
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Affiliation(s)
- Hidenori Suzuki
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Mai Yokoi
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sumitaka Hagiwara
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Eiichi Sasaki
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshiaki Kobayashi
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Sho Iwaki
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Daisuke Nishikawa
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shintaro Beppu
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hoshino Terada
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Michi Sawabe
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobuhiro Hanai
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
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21
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McCormick JP, Raskin J, Lee JT. Tension Pneumocephalus Following Balloon Sinuplasty. Ear Nose Throat J 2021; 100:859S-861S. [PMID: 34392735 DOI: 10.1177/01455613211037629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Balloon sinus dilation (BSD) is a common method of relieving sinus outflow obstruction. With the rising utilization of BSD, increasing numbers of BSD-related complications have also been reported. Here, we report a case of pneumocephalus and cerebrospinal fluid leak following BSD of the frontal sinus. Additionally, a review of the literature regarding BSD complications was performed.
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Affiliation(s)
- Justin P McCormick
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Jonathan Raskin
- Oakland University William Beaumont School of Medicine, Detroit MI, USA.,Cedars Sinai Sinus Center of Excellence, Los Angeles, CA, USA
| | - Jivianne T Lee
- Department of Head and Neck Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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22
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Srinivasa R, Chandrakiran C, Luckose R. Bilateral Posterior Nasoseptal Flap - Double Breasting Technique. Neurol India 2021; 69:307-310. [PMID: 33904440 DOI: 10.4103/0028-3886.314538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background and Introduction The success of endoscopic skull base surgery is largely based on the effective repair of the skull base defect. A pedicled nasoseptal flap (NSF), described by Hadad-Bassagateguy is the workhorse of contemporary endoscopic skull base repair. We describe a modification in the technique, "double breasting technique," using the bilateral posterior NSF for skull base repair. Objective In this video article, we describe the technique of harvesting bilateral posterior nasal septal flaps and overlaying the flaps in a double breasting technique to cover the skull base defect. The posterior NSF can be used to cover medium to large skull base defects effectively. Surgical Technique A 40-year-old female patient presented with headache and decreased vision for 2 months. MRI with gadolinium showed a sellar suprasellar lesion with chiasmal compression. Visual field charting showed bitemporal hemianopia. She underwent endoscopic transnasal transsphenoidal surgery (binostril approach) and complete excision of tumor. Intraoperatively, there was evidence of arachnoid breach with high flow cerebrospinal fluid (CSF) leak. Sella was repaired with fat, fascia, fibrin glue, and overlaid with the bilateral posterior NSF in a double breasting technique, as described in the video. Results The skull base repair was successful, with no CSF leak postoperatively.
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Affiliation(s)
- Rakshith Srinivasa
- Department of Neurosurgery, M S Ramaiah Memorial Hospital, Bangalore, Karnataka, India
| | - C Chandrakiran
- Department of Ear Nose and Throat, M S Ramaiah Medical College and Hospital, Bangalore, Karnataka, India
| | - Rini Luckose
- Department of Ear Nose and Throat, M S Ramaiah Medical College and Hospital, Bangalore, Karnataka, India
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23
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Shay A, Sturgis M, Ritz EM, Beer-Furlan A, Muñoz L, Byrne R, Tajudeen BA, Batra PS. Prior smoking and nasoseptal flap usage adversely impact quality of life and healing after endoscopic pituitary surgery. Neurosurg Focus 2021; 48:E17. [PMID: 32480369 DOI: 10.3171/2020.3.focus2050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endoscopic pituitary surgery (EPS) via the endonasal transsphenoidal approach is well established as an effective treatment modality for sellar masses. The objective of this study was to determine the relationship between key patient and operative variables and rhinological outcomes as determined by the 22-item Sino-Nasal Outcome Test (SNOT-22) and endoscopic scores following EPS. METHODS Prospectively collected SNOT-22 scores and objective endoscopic data were analyzed from a cohort of 109 patients who underwent EPS and had at least 90 days of postoperative follow-up. Trends in postoperative SNOT-22 scores were analyzed using linear mixed-effects models. Time to return to baseline endoscopic score was analyzed using Cox regression. RESULTS After adjusting for age and sex, the authors found that prior smokers had higher total and rhinological subdomain SNOT-22 scores (p < 0.01, 95% CI 5.82-16.39; p = 0.01, 95% CI 1.38-5.09, respectively) following EPS. Nasoseptal flap use also showed higher total and rhinological subdomain SNOT-22 scores (p = 0.01, 95% CI 1.62-12.60; p = 0.02, 95% CI 0.42-4.30, respectively). Prior sinonasal surgery and concurrent septoplasty did not affect the change in SNOT-22 total scores over time (p = 0.08, 95% CI -0.40 to 0.02; p = 0.33, 95% CI -0.09 to 0.29). CONCLUSIONS The findings suggest that the evolution of healing and patient-reported quality of life (QOL) measures are multifaceted with contributions from two key variables. Nasoseptal flap usage and prior smoking status may adversely impact postoperative QOL. No variables were found to be associated with objective postoperative endoscopic findings.
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Affiliation(s)
| | | | | | - Andre Beer-Furlan
- 3Rush Center for Skull Base and Pituitary Surgery, and.,Departments of4Neurosurgery and
| | - Lorenzo Muñoz
- 3Rush Center for Skull Base and Pituitary Surgery, and.,Departments of4Neurosurgery and
| | - Richard Byrne
- 3Rush Center for Skull Base and Pituitary Surgery, and.,Departments of4Neurosurgery and
| | - Bobby A Tajudeen
- 3Rush Center for Skull Base and Pituitary Surgery, and.,5Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
| | - Pete S Batra
- 3Rush Center for Skull Base and Pituitary Surgery, and.,5Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois
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24
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Eden JK, Böttcher A, Betz CS. Nasoseptal Flap for Skull Base Reconstruction in a Three-Year-Old Child With Nasofrontal Meningoencephalocele. Ear Nose Throat J 2021; 102:NP149-NP153. [PMID: 33645258 DOI: 10.1177/0145561321995017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Congenital anterior skull base defects with meningoencephaloceles causing nasal obstruction and cerebrospinal fluid (CSF) rhinorrhea are rare clinical entities. Traditionally, skull base defects have been repaired via a bifrontal craniotomy. With the introduction of pediatric endoscopic instrumentation, more of these lesions are accessible via an intranasal endoscopic approach, even in the infant population. However, due to the rarity of pediatric meningoencephaloceles, there is a lack of data demonstrating the successful adaptation of endoscopic skull base techniques to the pediatric population. In this report, we present a case of a pediatric frontonasal meningoencephalocele with an anterior skull base defect in a 3-year-old child that was successfully addressed transnasally following 4 failed transcranial approaches. The case highlights the importance of a thorough preoperative evaluation of the surgical approach as well as interdisciplinary management of these patients at a young age. Congenital anterior skull base defects with meningoencephaloceles and CSF leaks are rare clinical entities. Hence, an interdisciplinary approach is vital including experienced pediatricians, otolaryngologists, and neurosurgeons to evaluate the ideal surgical method on an individual basis. The transnasal endoscopic technique has been shown to be minimally invasive, efficient, and safe to apply even to the infant population which could positively be demonstrated in this case.
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Affiliation(s)
- Jördis Kristin Eden
- Department of Otorhinolaryngology, Skull Base Center, 37734University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne Böttcher
- Department of Otorhinolaryngology, Skull Base Center, 37734University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Stephan Betz
- Department of Otorhinolaryngology, Skull Base Center, 37734University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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25
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Carnevale C, Til-Pérez G, Tomás-Barberán M, Ibañez-Domínguez J, Arancibia-Tagle D, Sarría-Echegaray P. Middle turbinate mucosal flap: Low-morbidity option in the management of skull base defects. Head Neck 2021; 43:1415-1420. [PMID: 33433950 DOI: 10.1002/hed.26613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To describe the low morbidity of middle turbinate mucosal flap (MTMF) to repair anterior skull base defects. METHODS Skull base endonasal endoscopic surgeries performed at a tertiary hospital between 2015 and 2018 were analyzed. Patients were divided into two groups according the existence or not of a significant intraoperative cerebrospinal fluid (CSF) leak. In Group 1 (n = 28), gasket seal and a pedicled endonasal flap were used to repair the defect: 13 nasoseptal flaps (NSF), 8 inferolateral wall flaps (ILF), and 7 MTMF. In Group 2 only an endonasal flap was used: 9 NSF, 4 ILF, and 18 MTMF. Surgical and recovery time were analyzed (Student's t test). Our favorite surgical technique is described. RESULTS Fifty-nine patients were included. Average surgical time was 27.7, 41.6, and 11.3 min for NSF, ILF, and MTMF, respectively. MTMF showed a faster recovery. CONCLUSION MTMF is a safe reconstructive option for anterior skull base defects.
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Affiliation(s)
- Claudio Carnevale
- Department of Otorhinolaryngology - Head and Neck Surgery, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Guillermo Til-Pérez
- Department of Otorhinolaryngology - Head and Neck Surgery, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Manuel Tomás-Barberán
- Department of Otorhinolaryngology - Head and Neck Surgery, Son Espases University Hospital, Palma de Mallorca, Spain
| | | | - Diego Arancibia-Tagle
- Department of Otorhinolaryngology - Head and Neck Surgery, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Pedro Sarría-Echegaray
- Department of Otorhinolaryngology - Head and Neck Surgery, Son Espases University Hospital, Palma de Mallorca, Spain
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26
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Chou CT, Valappil B, Mattos JL, Snyderman CH, Gardner PA, Fernandez-Miranda JC, Wang EW. The Effect of Nasoseptal Flap Elevation on Post-Operative Olfaction and Sinonasal Quality of Life: A Prospective Double-Blinded Randomized Controlled Trial. Am J Rhinol Allergy 2020; 35:353-360. [PMID: 32921136 DOI: 10.1177/1945892420957505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of nasoseptal flaps (NSF) for defect reconstruction in endoscopic endonasal approaches (EEA) to cranial base pathology has markedly reduced rates of cerebrospinal fluid leak. However, the effect of NSF use on post-operative olfaction remains unclear. OBJECTIVE To evaluate the impact of NSF use during EEA on binarial and uninarial olfaction, and sinonasal quality of life (QOL). METHODS This was a prospective double-blinded randomized controlled trial. Patients undergoing EEA for sellar pathology were recruited from the University of Pittsburgh Medical Center from December 2014 to May 2017. Subjects were randomized pre-operatively to a side of NSF harvest. Olfaction and QOL were assessed pre-operatively and 6 to 12 months post-operatively using the University of Pennsylvania Smell Identification Test, "Sniffin' Sticks," and Sinonasal Outcomes Test 22. The side of dominant uninarial olfaction was determined using "Sniffin' Sticks." RESULTS Thirty-one patients were enrolled. Sixteen underwent EEA without NSF (control group) and 15 with NSF. A dominant side of olfaction was identified in 14 patients with NSF; 8 patients were randomized to NSF harvest on the dominant side and the remaining 6 on the non-dominant side. NSF elevation resulted in a 4% decrease in University of Pennsylvania Smell Identification Test scores, but was not statistically significant compared to controls. Similarly, NSF elevation on the side of dominant olfaction resulted in a 6% decrease, but was not statistically significant when compared to the non-dominant elevation group. Change in rhinologic QOL as determined by the Sinonasal Outcomes Test 22 was not significantly different between any of the groups. CONCLUSIONS The use of NSF during EEA for sellar pathology does not have a significant effect on olfaction or rhinologic QOL. The presence of a dominant side of olfaction is not a primary consideration when deciding the side of NSF harvest.
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Affiliation(s)
- Courtney T Chou
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Benita Valappil
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jose L Mattos
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia
| | - Carl H Snyderman
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Eric W Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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27
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Hannan CJ, Kelleher E, Javadpour M. Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review. Front Oncol 2020; 10:1614. [PMID: 32850466 PMCID: PMC7431707 DOI: 10.3389/fonc.2020.01614] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/24/2020] [Indexed: 01/04/2023] Open
Abstract
Following the introduction of fully endoscopic techniques for the resection of pituitary tumors, there was a rapid expansion of the indications for endonasal endoscopic surgery to include extrasellar tumors of the skull base. These techniques offer significant advantages over traditional open surgical approaches to the skull base, including improved tumor resection, and better post-operative neurological outcomes. Following their introduction, however, the initial rate of post-operative CSF leak was unacceptably high. Post-operative CSF leak following skull base surgery is a major source of morbidity, and can lead to the development of life-threatening intracranial infection. The use of vascularized naso-septal flaps transformed the management of these patients, significantly reducing the rate of post-operative CSF leak and increasing the number of patients that could benefit from this less invasive treatment modality. Adequate repair of iatrogenic defects in the skull base is of crucial importance for patients with skull base tumors, as the development of a post-operative CSF leak, and the associated complications can significantly delay the administration of the adjunctive oncological therapies these patients require. In this review, we provide an overview of the latest evidence regarding skull base reconstruction following endoscopic skull base surgery, and describe the skull base repair technique in use at our institution.
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Affiliation(s)
- Cathal John Hannan
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester, United Kingdom
| | - Eoin Kelleher
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Dublin, Ireland
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28
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Shastri KS, Lin Y, Scordino J, Pinheiro-Neto CD. Composite Cartilage-osseous-mucosal Nasoseptal Flap for Reconstruction after Near Total Rhinectomy. Ann Otol Rhinol Laryngol 2020; 130:98-103. [PMID: 32578449 DOI: 10.1177/0003489420935481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reconstruction of full thickness nasal defects usually requires different donor sites for the external skin envelope, structural elements, and internal nasal lining. In this paper we present a novel single site method for dual inner lining and skeleton repair for full thickness nasal defects with a composite nasoseptal flap and extended pedicle dissection. METHODS A 72-year-old male presented with a T4b melanoma involving the nasal dorsum and left upper lateral cartilage. Following full thickness resection, reconstruction was performed with a nasoseptal flap (NSF) with attached septal cartilage and vomer in conjunction with a paramedian forehead flap. Extended pedicle dissection into the pterygopalatine fossa allowed the NSF to fully cover the defect. RESULTS The nasal defect was fully corrected. There was no evidence of flap compromise or nasal valve stenosis at 1 month, 2 month, and 1 year follow-up visits. CONCLUSIONS We present here the first successful application of a composite cartilage-osseous-mucosal NSF for multilayered nasal reconstruction. In appropriate patients, this technique may obviate the need for flaps or grafts from extranasal sources, limiting donor site morbidity.
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Affiliation(s)
- Karthik S Shastri
- Division of Otolaryngology / Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - Yufan Lin
- Albany Medical College, Albany, NY, USA
| | - Jessica Scordino
- Division of Otolaryngology / Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - Carlos D Pinheiro-Neto
- Division of Otolaryngology / Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, NY, USA
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29
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Soneru CP, Riley CA, Minkowitz S, Tabaee A, Anand VK, Schwartz TH. Adherus Dural Sealant in Endoscopic Skull Base Surgery: Safety, Imaging Characteristics, and Sinonasal Quality of Life. J Neurol Surg B Skull Base 2019; 81:659-663. [PMID: 33381370 DOI: 10.1055/s-0039-1694048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022] Open
Abstract
Objective This study was aimed to compare the safety profiles, magnetic resonance imaging (MRI) findings, and sinonasal outcome test (SNOT-22) scores of Adherus dural sealant, a novel tissue glue designed for skull base surgery. Design Present study is a prospective case series. Setting The research work took place at a tertiary-care academic medical center. Participants Consecutive series of 26 patients undergoing endoscopic skull base surgery (ESBS) with Adherus was compared with a control group of 24 patients matched for tumor type and size with DuraSeal as a sealant. Main Outcome Measures Postoperative complication rates, imaging characteristics, and postoperative SNOT-22 scores were measured and compared. Results No postoperative cerebrospinal fluid (CSF) leaks, intracranial hemorrhages, or mucoceles were observed in either cohort. Adherus was more likely to be identifiable on immediate postoperative MRI (50 vs. 20.8%, p = 0.032). In patients in whom a nasoseptal flap was utilized, the flap was opposed to the skull base in all cases regardless of sealant selected. Postoperative SNOT-22 total (17.25 [±10.81] vs. 14.85 [±14.22], p = 0.609) and subdomain scores were similar between the two groups. Conclusions Adherus dural sealant appears to be a safe alternative to Duraseal in ESBS with comparable quality of life outcomes and imaging findings. These preliminary results are promising but should be examined in a larger population with long-term follow-up.
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Affiliation(s)
- Christian P Soneru
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Charles A Riley
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Shlomo Minkowitz
- Departments of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Abtin Tabaee
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Vijay K Anand
- Departments of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
| | - Theodore H Schwartz
- Departments of Neurosurgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, United States
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30
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Khatiwala RV, Shastri KS, Peris-Celda M, Kenning T, Pinheiro-Neto CD. Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata "Button" Graft and Nasoseptal Flap: Surgical Technique and Case Series. J Neurol Surg B Skull Base 2019; 81:645-650. [PMID: 33381368 DOI: 10.1055/s-0039-1693124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 05/19/2019] [Indexed: 10/26/2022] Open
Abstract
Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m 2 (median = 31 kg/m 2 ), with 18 patients meeting criteria for obesity (BMI > 30 kg/m 2 ) and 12 patients overweight (25 kg/m 2 < BMI < 29.9 kg/m 2 ). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.
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Affiliation(s)
| | - Karthik S Shastri
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, New York, United States
| | - Maria Peris-Celda
- Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
| | - Tyler Kenning
- Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
| | - Carlos D Pinheiro-Neto
- Division of Otolaryngology/Head and Neck Surgery, Department of Surgery, Albany Medical Center, Albany, New York, United States.,Department of Neurosurgery, Albany Medical Center, Albany, New York, United States
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31
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Griffiths CF, Barkhoudarian G, Cutler A, Duong HT, Karimi K, Doyle O, Carrau R, Kelly DF. Analysis of Olfaction after Bilateral Nasoseptal Rescue Flap Transsphenoidal Approach with Olfactory Mucosal Preservation. Otolaryngol Head Neck Surg 2019; 161:881-889. [PMID: 31331243 DOI: 10.1177/0194599819861340] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To ascertain the impact of septal olfactory strip preservation and bilateral rescue flap elevation on the incidence of olfactory dysfunction. STUDY DESIGN Case series with chart review of patients undergoing endoscopic endonasal skull base surgery (2012-2014). SETTING Providence Saint John's Health Center and John Wayne Cancer Institute. SUBJECTS AND METHODS The incidences of postoperative epistaxis, hyposmia, and anosmia were analyzed using the Brief Smell Identification Test (B-SIT), which was completed in 110 of the 165 patients. RESULTS Seventy-eight patients required extended approaches. Bilateral nasoseptal rescue flaps were elevated in 144 patients (87.3%) and pedicled nasoseptal or middle turbinate flaps in 21 patients (12.7%). The neurovascular pedicles were preserved in all patients, and there were no episodes of postoperative arterial epistaxis. Normal olfaction was noted in 95 patients (86%), with new hyposmia noted in 5 patients (5.5%). Within the rescue flap cohort, new hyposmia occurred in 6.3% (P < .01) of patients, balanced by improvement of olfaction in 43% of patients with preoperative dysfunction (overall pre- and postoperative olfactory function: 85% vs 86%). Patients with pedicled nasoseptal flaps did not have new hyposmia, with a net improvement of olfaction (71% vs 86%, P = .07). No patients experienced new anosmia. There was no difference between flap type within either subgroup. CONCLUSIONS Superior olfactory strip preservation during elevation of reconstructive flaps preserves olfactory function and maintains adequate surgical exposure. In addition, rescue flaps have significantly diminished the rate of arterial postoperative epistaxis while maintaining the ability to harvest nasoseptal flaps for future reconstruction.
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Affiliation(s)
- Chester F Griffiths
- Pacific Neuroscience Institute & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
| | - Aaron Cutler
- Inland Neurosurgery Institute, Pomona, California, USA
| | - Huy T Duong
- University of California, Davis Medical School, Davis, California and The Kaiser Permanente Medical Group, Sacramento, California, USA
| | - Kian Karimi
- Pacific Eye and Ear Specialists, Los Angeles, California, USA
| | - Olivia Doyle
- Pacific Eye and Ear Specialists, Los Angeles, California, USA
| | - Ricardo Carrau
- Comprehensive Skull Base Surgery Program, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute & Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California, USA
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32
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Naumenko AN, Gaidukov SS, Gulyaev DA, Konoplev OI, Chernushevich II, Zakharova GP. [Skull base defects multilayer plasty in patients with spontaneous cerebrospinal fluid leak: our experience]. Vestn Otorinolaringol 2019; 84:51-54. [PMID: 30938343 DOI: 10.17116/otorino20198401151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Spontaneous cerebrospinal fluid (CSF) leak is one of the types of non-traumatic CSF leaks in which the etiologic factor is unknown. Skull base defects transnasal endoscopic plasty is the initial method of surgical repair of spontaneous cerebrospinal fluid leaks. METHODS: Forty-five patients with spontaneous CSF leaks were managed using multilayer transplant technique. The basic choice criteria of endoscopic transnasal surgical approach and materials to reconstruction of skull base defects were the size of defect and its localization. In all cases pediculated flaps in combination with free graft were used. RESULTS: In 43 (96%) cases CSF leaks was successfully managed in primary surgery, which indicates high efficiency of the described surgical interventions.
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Affiliation(s)
- A N Naumenko
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - S S Gaidukov
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - D A Gulyaev
- V.A. Almazov National Medical Research Centre, Saint Petersburg, Russia, 197341
| | - O I Konoplev
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - I I Chernushevich
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - G P Zakharova
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
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33
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McCormick J, Allen M, Kain JJ, Pena-Garcia JA, Cho DY, Riley KO, Woodworth BA. Lateral nasal wall extension of the nasoseptal flap for skull-base and medial orbital wall defects. Int Forum Allergy Rhinol 2019; 9:1041-1045. [PMID: 31173672 DOI: 10.1002/alr.22364] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sinonasal and skull-base tumors that previously required open resection can often be completely resected via an endonasal approach. The nasoseptal flap (NSF) is the workhorse vascularized tissue flap for the endoscopic reconstruction of large skull-base defects from tumor resections. The objective of the current article is to describe a novel modification of the NSF for simultaneous reconstruction of skull-base and medial orbital wall defects. METHODS An extension of the standard NSF to include mucosa of the lateral nasal wall was developed for closure of simultaneous skull-base and medial orbital wall defects. Outcomes including successful cerebrospinal fluid (CSF) leak closure, orbital edema, and postoperative cosmesis are reported. Eyelid edema was characterized according to the Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) scale. RESULTS Three patients underwent reconstruction using the modified NSF (average age 75 years). The average defect size of the skull base was 3.6 ± 0.1 cm by 2.3 ± 0.2 cm. The average defect size of the medial orbit was 2.7 ± 0.1 cm by 2.6 ± 0.1 cm. All defects were successfully covered intraoperatively using the lateral nasal wall extension of the NSF. Two patients developed mild eyelid edema, whereas 1 individual had no noticeable swelling (SPREE classification 2, 2, and 1). All patients were successfully sealed at last clinical follow up (average 28 weeks). CONCLUSION The modification of the NSF described here provides excellent coverage for reconstruction of large anterior skull-base defects and simultaneous medial orbital wall defects.
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Affiliation(s)
- Justin McCormick
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Mark Allen
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Joshua J Kain
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jaime A Pena-Garcia
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Do-Yeon Cho
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL
| | - Bradford A Woodworth
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
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34
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Kuan EC, Trent MS, Luu NN, Kohanski MA, Tong CC, O'Malley BW, Adappa ND, Palmer JN. Preventing Restenosis of Marsupialized Rathke Cleft Cysts Using a Nasoseptal Flap Lining. Laryngoscope 2019; 129:2258-2261. [PMID: 31038765 DOI: 10.1002/lary.28053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/01/2019] [Accepted: 04/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Rathke cleft cysts (RCCs) are rare, benign lesions formed from remnants of Rathke pouch during embryologic development. However, following marsupialization, maintaining tract patency remains a challenge. Several techniques for decreasing stenosis have been described, including free mucosal grafting, silastic spacing, and using steroid-eluting stents. Nasoseptal flaps (NSFs) have a reliable vascular supply and are widely utilized in skull base reconstruction. We present a novel technique to maintain patency of the marsupialized RCC cavity by lining it with an NSF to promote long-term drainage and re-epithelialization of the RCC cavity. METHODS Retrospective chart review of all patients who underwent surgery for symptomatic RCCs. These patients underwent endoscopic endonasal surgery between February 3, 2016, and June 12, 2018, with marsupialization followed by circumferential NSF lining. Primary outcomes include symptomatic control, surgical complications, and RCC cavity patency. RESULTS Seven patients underwent RCC marsupialization with no intraoperative cerebrospinal fluid leak, followed by circumferential lining of the marsupialized cavity with an NSF. In each case, no cyst re-accumulation or recurrent symptoms were noted, and the NSF lining provided long-term patency of the tract in all cases to a mean of 6.7 ± 10.1 months of follow-up, including one patient with sustained patency at 29 months follow-up. CONCLUSION Utilization of the NSF to "stent open" the RCC cavity following marsupialization is a safe and effective means to prevent restenosis. Advantages include sustained patency of RCC cavity for complete drainage and a dependable vascular supply. LEVEL OF EVIDENCE 4 Laryngoscope, 129:2258-2261, 2019.
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Affiliation(s)
- Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California
| | - Monica S Trent
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, California
| | - Neil N Luu
- and the Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Michael A Kohanski
- and the Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Charles C Tong
- and the Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- and the Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Nithin D Adappa
- and the Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - James N Palmer
- and the Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Puccinelli CL, Yin LX, O'Brien EK, Van Gompel JJ, Choby GW, Van Abel KM, Janus JR, Stokken JK. Long-term olfaction outcomes in transnasal endoscopic skull-base surgery: a prospective cohort study comparing electrocautery and cold knife upper septal limb incision techniques. Int Forum Allergy Rhinol 2019; 9:493-500. [PMID: 30657649 DOI: 10.1002/alr.22291] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/24/2018] [Accepted: 12/27/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Olfactory nerve fibers are at risk of injury during transnasal endoscopic skull-base approaches. Olfactory outcomes for various techniques have not been thoroughly investigated. This study aims to report long-term olfactory outcomes when a cold knife upper septal limb incision technique is used compared to monopolar cautery. METHODS A prospective cohort study was performed at a tertiary referral center. Adult patients undergoing endoscopic approaches with septal incisions were randomized to cold knife or monopolar cautery groups. Patient demographics, clinical history, surgical data, and outcomes were collected. Preoperative, 3-month, and 12-month postoperative scores on the University of Pennsylvania Smell Inventory Test (UPSIT) and 22-item Sino-Nasal Outcome Test (SNOT-22) were measured. Fisher's exact tests were performed for categorical variables and t tests were performed for continuous variables. RESULTS Twenty-two (22) patients (10 cold knife, 12 cautery) were enrolled between March 2016 and August 2017. The average age ± standard deviation was 50.2 ± 14.0 years (p = 0.59), 54% (p = 0.69) were female, and the primary pathology was pituitary adenoma (73%, p = 1.00). Preoperative, 3-month, and 12-month postoperative UPSIT scores were similar between the cold knife and cautery groups (32.8 vs 32.4, p = 0.80; 33.1 vs 33.0, p = 0.96; 33.6 vs 33.3, p = 0.84). On the "sense of smell/taste" question of the SNOT-22, there was also no difference at all time points (p > 0.22). CONCLUSION There was no significant change in patient UPSIT scores 1 year after transnasal skull-base approaches, and no short-term or long-term differences between cold knife and cautery upper septal limb incision techniques. Our study supports an individualized approach based on surgeon preference.
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Affiliation(s)
| | - Linda X Yin
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Erin K O'Brien
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | | | - Garret W Choby
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Kathryn M Van Abel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Jeffrey R Janus
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Janalee K Stokken
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
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Riley CA, Tabaee A, Conley L, Amine M, Soneru CP, Anand VK, Schwartz TH. Long-term sinonasal outcomes after endoscopic skull base surgery with nasoseptal flap reconstruction. Laryngoscope 2018; 129:1035-1040. [PMID: 30569585 DOI: 10.1002/lary.27637] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 09/14/2018] [Accepted: 10/04/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The utilization of the nasoseptal flap (NSF) in endoscopic anterior skull base surgery (EASB) has resulted in reduced rates of postoperative cerebrospinal fluid leak (CSF). The long-term impact on sinonasal function after surgery remains incompletely defined. METHODS A consecutive series of patients undergoing EASB with NSF and with at least 3 years follow-up was prospectively evaluated. Patient demographics, pre- and postoperative Sino-nasal Outcome Test-22 (SNOT-22) scores, Lund-Mackay scores (LMS), CSF leak, and sinonasal complications were analyzed. RESULTS A total of 46 patients undergoing EASB with NSF met inclusion criteria. The mean follow-up was 67.4 months (range 39-90, standard deviation [SD] 14.2 months). No statistically significant differences were noted between the mean overall pre- (16) and postoperative SNOT-22 scores (18). SNOT-22 scores improved in 27 patients (58.7%), deteriorated in 17 patients (37.0%) and stayed the same in two patients (4.3%). Deterioration in SNOT-22 scores was greater in younger (mean change + 7.2 [SD17.4] vs. older patients -3.4 [SD 7.5], P = 0.010). A statistically significant increase in LMS was noted (mean preoperative LMS0.9 vs. mean postoperative LMS 2.2, P = 0.001). The LMS decreased in nine patients (19.6%), increased in 22 patients (47.8%), and remained the same in 15 patients (32.6%). One patient (2.2%) developed a postoperative CSF leak following resection of metastatic skull base lesion and was successfully treated with placement of a lumbar drain, Foley catheter balloon, and strict bed rest. One patient (2.2%) developed a postoperative mucocele requiring decompression 3 years after initial surgery. CONCLUSION Whereas long-term sinonasal quality of life is overall improved in the majority of patients following NSF use for EASB, younger patients show higher incidence of deterioration. Increased sinus opacification on imaging is generally noted and may require continued follow-up and management. The incidence of reoperation for symptomatic mucocele formation is low. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1035-1040, 2019.
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Affiliation(s)
- Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Abtin Tabaee
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Lindsey Conley
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Muhamad Amine
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Christian P Soneru
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Vijay K Anand
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
| | - Theodore H Schwartz
- Department of Neurosurgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, New York, U.S.A
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Seo MY, Nam DH, Kong DS, Lee JJ, Ryu G, Kim HY, Dhong HJ, Chung SK, Lee KE, Hong SD. Quality of life after extended versus transsellar endoscopic skull base surgery from 767 patients. Laryngoscope 2018; 129:1318-1324. [PMID: 30569447 DOI: 10.1002/lary.27630] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of this study was to compare sinonasal-related quality of life (QOL) in patients treated by extended or transsellar endoscopic skull base surgery. STUDY DESIGN Prospective data analysis. METHODS Prospectively collected data from patients who underwent endoscopic skull base surgery between 2012 and 2017 were analyzed. Primary outcomes were preoperative Sino-Nasal Outcome Test-20 (SNOT-20) scores and then 1-month, 3-month, and 6-month follow-up. Comparative analysis was performed between the endoscopic transsellar approach (ETA) group (n = 647) and an extended endoscopic endonasal approach (EEEA) group (n = 120). In ETA group, the SNOT-20 score was compared between patients with a nasoseptal flap (NSF) (ETA-NSF) and without an NSF (ETA-no NSF). RESULTS The mean total SNOT-20 score was significantly worse in the EEEA than ETA group at 1, 3, and 6 months postoperatively (P < .05). Although there was no significant difference in total SNOT-20 score between the ETA-NSF and ETA-no NSF group at 3 and 6 months after surgery, the percentage of patients with significant change (≥0.8) in the SNOT-20 score was higher in the NSF used group at 1, 3, and 6 months postoperatively (22.92% vs. 13.51%, P = .029; 20.59% vs. 5.59%, P = .039; and 24.00% vs. 4.03%, P = .003, respectively). According to multivariate analysis conducted regarding factors that deteriorate sinonasal QOL at 6 months following surgery, only NSF usage is significantly associated with poor outcome (odds ratio: 4.371, P = .011) CONCLUSIONS: Sinonasal-related QOL was significantly worse in patients treated by the EEEA versus ETA. Use of an NSF is the only poor prognostic factor in sinonasal QOL after endoscopic skull base surgery. LEVEL OF EVIDENCE 2b Laryngoscope, 129:1318-1324, 2019.
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Affiliation(s)
- Min Young Seo
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, South Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Joo Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gwanghui Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hun-Jong Dhong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Kyu Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyung Eun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Zwagerman NT, Wang EW, Shin SS, Chang YF, Fernandez-Miranda JC, Snyderman CH, Gardner PA. Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 2018; 131:1-7. [PMID: 30485224 DOI: 10.3171/2018.4.jns172447] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/17/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE: Based on a null hypothesis that the use of short-term lumbar drainage (LD) after endoscopic endonasal surgery (EES) for intradural pathology does not prevent postoperative CSF leaks, a trial was conducted to assess the effect of postoperative LD on postoperative CSF leak following standard reconstruction. METHODS: A prospective, randomized controlled trial of lumbar drain placement after endoscopic endonasal skull base surgery was performed from February 2011 to March 2015. All patients had 3-month follow-up data. Surgeons were blinded to which patients would or would not receive the drain until after closure was completed. An a priori power analysis calculation assuming 80% of power, 5% postoperative CSF leak rate in the no-LD group, and 16% in the LD group determined a planned sample size of 186 patients. A routine data and safety check was performed with every 50 patients being recruited to ensure the efficacy of randomization and safety. These interim tests were run by a statistician who was not blinded to the arms they were evaluating. This study accrued 230 consecutive adult patients with skull base pathology who were eligible for endoscopic endonasal resection. Inclusion criteria (high-flow leak) were dural defect greater than 1 cm2 (mandatory), extensive arachnoid dissection, and/or dissection into a ventricle or cistern. Sixty patients were excluded because they did not meet the inclusion criteria. One hundred seventy patients were randomized to either receive or not receive a lumbar drain. RESULTS: One hundred seventy patients were randomized, with a mean age of 51.6 years (range 19-86 years) and 38% were male. The mean BMI for the entire cohort was 28.1 kg/m2. The experimental cohort with postoperative LD had an 8.2% rate of CSF leak compared to a 21.2% rate in the control group (odds ratio 3.0, 95% confidence interval 1.2-7.6, p = 0.017). In 106 patients in whom defect size was measured intraoperatively, a larger defect was associated with postoperative CSF leak (6.2 vs 2.9 cm2, p = 0.03). No significant difference was identified in BMI between those with (mean 28.4 ± 4.3 kg/m2) and without (mean 28.1 ± 5.6 kg/m2) postoperative CSF leak (p = 0.79). Furthermore, when patients were grouped based on BMI < 25, 25-29.9, and > 30 kg/m2, no difference was noted in the rates of CSF fistula (p = 0.97). CONCLUSIONS: Among patients undergoing intradural EES judged to be at high risk for CSF leak as defined by the study's inclusion criteria, perioperative LD used in the context of vascularized nasoseptal flap closure significantly reduced the rate of postoperative CSF leaks.Clinical trial registration no.: NCT03163134 (clinicaltrials.gov).
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Affiliation(s)
| | - Eric W Wang
- Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | - Carl H Snyderman
- Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Lavigne P, Faden DL, Wang EW, Snyderman CH. Complications of Nasoseptal Flap Reconstruction: A Systematic Review. J Neurol Surg B Skull Base 2018; 79:S291-S299. [PMID: 30210981 DOI: 10.1055/s-0038-1668158] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022] Open
Abstract
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.
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Affiliation(s)
- Philippe Lavigne
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Daniel L Faden
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Nayak JV, Rathor A, Grayson JW, Bravo DT, Velasquez N, Noel J, Beswick DM, Riley KO, Patel ZM, Cho DY, Dodd RL, Thamboo A, Choby GW, Walgama E, Harsh GR, Hwang PH, Clemons L, Lowman D, Richman JS, Woodworth BA. Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling. Int Forum Allergy Rhinol 2018; 8:1162-1168. [PMID: 29856526 DOI: 10.1002/alr.22156] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Aakanksha Rathor
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jessica W Grayson
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Dawn T Bravo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Nathalia Velasquez
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Julia Noel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Daniel M Beswick
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama Birmingham, Birmingham, AL
| | - Zara M Patel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Do-Yeon Cho
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Robert L Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Andrew Thamboo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Garret W Choby
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Evan Walgama
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Griffith R Harsh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Lisa Clemons
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Deborah Lowman
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Joshua S Richman
- Department of Neurosurgery, University of Alabama Birmingham, Birmingham, AL
| | - Bradford A Woodworth
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL
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Lucke-Wold B, Mendez G, Cua D, Akins P, Gillham H, Ciporen J. Combined Endoscopic Transorbital and Endonasal Repair of High Flow Orbital Apex/Middle Fossa Cerebrospinal Fluid Leak with a Nasoseptal Flap. J Neuroinflamm Neurodegener Dis 2018; 2:100005. [PMID: 29676403 PMCID: PMC5903292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND IMPORTANCE High flow orbital apex or middle fossa cerebrospinal fluid (CSF) leaks can be life threatening and complex to repair. These leaks associated with large dural defects are most commonly repaired with an open temporalis muscle patch or free flaps, but these flaps do not always stop the leak. CLINICAL PRESENTATION A 65-year-old patient presented two years after orbital exenteration and radiation for squamous cell carcinoma. He developed multi-organism meningitis and pneumocephalus secondary to a large high-flow orbital apex/middle fossa CSF leak. To repair the leak, a combined endoscopic transorbital/endonasal approach with pedicled nasospetal flap and dermis fat graft was used. We describe the unique endoscopic technique that was used to treat the life threatening high flow orbital apex/middle fossa CSF leak. The technique allowed the use of the transposed pedicled flap, which is an alternative to the free flap in controlling CSF leak. Cisternogram post-operatively and clinical exam confirmed resolution of CSF leak. Although a critically ill patient at admission with a modified Rankin scale (MRS) of 5, he was discharged home on continued IV antibiotic therapy with a MRS of 3. Endoscopic evaluation at three months after treatment showed the effectiveness of the flap and he continued to improve clinically. CONCLUSION This is the first case to describe a combined endoscopic transorbital and endonasal repair of high flow orbital apex/middle fossa CSF leak with a pedicled nasoseptal flap. These techniques can be utilized during initial reconstruction after orbital exenteration or as a salvage flap.
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Affiliation(s)
- Brandon Lucke-Wold
- Department of Neurosurgery, West Virginia University School of Medicine, USA
| | - Gustavo Mendez
- Department of Radiology, Oregon Health and Science University, USA
| | - David Cua
- Department of Neurosurgery, The Permanente Medical Group, USA
| | - Paul Akins
- Department of Neurosurgery, The Permanente Medical Group, USA
| | - Haley Gillham
- Department of Neurosurgery, Oregon Health and Science University, USA
| | - Jeremy Ciporen
- Department of Neurosurgery, Oregon Health and Science University, USA
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Barger J, Siow M, Kader M, Phillips K, Fatterpekar G, Kleinberg D, Zagzag D, Sen C, Golfinos JG, Lebowitz R, Placantonakis DG. The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas. Surg Neurol Int 2018. [PMID: 29527390 PMCID: PMC5838838 DOI: 10.4103/sni.sni_192_17] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- James Barger
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Matthew Siow
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Michael Kader
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Katherine Phillips
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Girish Fatterpekar
- Department of Radiology, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - David Kleinberg
- Department of Medicine, New York University School of Medicine, New York, USA
| | - David Zagzag
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Pathology, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - Chandranath Sen
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - John G Golfinos
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - Richard Lebowitz
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, USA
| | - Dimitris G Placantonakis
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
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43
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Ben-Ari O, Wengier A, Ringel B, Carmel Neiderman NN, Ram Z, Margalit N, Fliss DM, Abergel A. Nasoseptal Flap for Skull Base Reconstruction in Children. J Neurol Surg B Skull Base 2018; 79:37-41. [PMID: 29404239 DOI: 10.1055/s-0037-1617435] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Objective The endoscopic endonasal approach is being increasingly used for the resection and reconstruction of anterior skull base (ASB) lesions. Vascularized nasoseptal flaps (NSF) have become the workhorse for the reconstruction of ASB defects, resulting in a significant decrease in the incidence of cerebrospinal fluid (CSF) leaks. The objective of this study was to investigate the efficacy and safety of NSF in children. Methods This is a retrospective analysis of the medical records of all patients under the age of 18 years who underwent endoscopic repair of ASB lesions with the use of NSF at our tertiary medical center between 1/2011 and 8/2016. Results Twelve children underwent ASB defect repair for both benign and malignant neoplasms using the endoscopic endonasal NSF technique. Four children had previously undergone ASB surgery. The male-to-female ratio was 1:1, the average age was 12.3 years, the average hospitalization time was 8.3 days, and the maximum follow-up period was 24 months, during which craniofacial growth appeared to be unimpaired. A lumbar drain was used postoperatively in six cases. Crust formation and synechia were observed in two cases. There was one case of a major long-term complication (a CSF leak followed by meningitis). Conclusions Endoscopic endonasal NSF was both an effective and a safe technique for ASB defect reconstruction in 12 children for both benign and malignant neoplasms. It had a high success rate and a low complication rate. No apparent negative influence on craniofacial growth was observed in our series.
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Affiliation(s)
- Oded Ben-Ari
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Wengier
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Ringel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Narin N Carmel Neiderman
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nevo Margalit
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Abergel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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44
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Patel VS, Choby GW, Thamboo A, Blevins NH, Hwang PH. Nasoseptal flap closure of the eustachian tube for recalcitrant cerebrospinal fluid rhinorrhea. Laryngoscope 2017; 128:1523-1526. [PMID: 29152752 DOI: 10.1002/lary.26988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/12/2017] [Accepted: 10/05/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Vishal S Patel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Garret W Choby
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.,Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Andrew Thamboo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nikolas H Blevins
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, U.S.A
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45
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Abstract
The success of expanded endoscopic endonasal approaches (EEAs) to the anterior skull base, sellar, and parasellar regions has been greatly aided by the advancement in reconstructive techniques. In particular, the pedicled vascularized flaps have been developed and effectively cover skull base defects of varying sizes with a significant reduction in postoperative CSF leaks. There are two aims to this review: (1) We will provide our current, simplified reconstruction algorithm. (2) We will describe, in detail, the relevant anatomy, indications/contraindications, and surgical technique, with a particular emphasis on the nasoseptal flap (NSF). The inferior turbinate flap (ITF), middle turbinate flap (MTF), pericranial flap (PCF), and temporoparietal fascial flap (TPFF) will also be described. The NSF should be the primary option for reconstruction of majority of skull base defects following endonasal endoscopic surgery. In general, for the planum, cribriform, and upper two-thirds of the clivus, the NSF is ideal. For the lower-third of the clivus, the NSF may not be adequate and may require additional reconstructive options. Although limited in reach or more technically challenging, these reconstructive flaps should still be considered and kept in the surgical algorithm.
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Affiliation(s)
- Srikant Chakravarthi
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Lior Gonen
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Alejandro Monroy-Sosa
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Sammy Khalili
- Department of Otorhinolaryngology, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Amin Kassam
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
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46
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Kuan EC, Yoo F, Patel PB, Su BM, Bergsneider M, Wang MB. An Algorithm for Sellar Reconstruction Following the Endoscopic Endonasal Approach: A Review of 300 Consecutive Cases. J Neurol Surg B Skull Base 2017; 79:177-183. [PMID: 29868324 DOI: 10.1055/s-0037-1606293] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 07/15/2017] [Indexed: 12/17/2022] Open
Abstract
Objectives/Hypotheses The endoscopic endonasal approach (EEA) is the workhorse endoscopic procedure for sellar and parasellar pathology. Various reconstruction techniques have been reported following EEA surgery, ranging from no reconstruction to vascularized flaps. We review our institution's experience with sellar reconstruction following EEA and propose an evidence-based algorithm. Design Retrospective review. Setting Tertiary academic medical center. Participants Patients who underwent endoscopic EEA surgery for sellar or parasellar pathology between March 1, 2013 and August 31, 2016. Main Outcome Measures Patient demographic and clinicopathologic data were collected. Outcome measures included intraoperative and postoperative cerebrospinal fluid (CSF) leak rates and extent of resection (gross or subtotal). Results Three hundred consecutive patients were included. Depending on the presence and grade of intraoperative CSF leak, cases were reconstructed using either a free mucosal graft (FMG) or nasoseptal flap (NSF). Intraoperative and postoperative CSF leak rates were 30.7% and 2.3%, respectively. Multivariable logistic regression found that intraoperative CSF leak was associated with recurrent disease (odds ratio [OR] 2.47, p = 0.004), with no apparent predictors of postoperative CSF leak. Conclusions Based on this large series, we propose the following algorithm for sellar reconstruction: FMG for no CSF leak; fat graft + FMG ± rigid fixation for low-grade leaks; and fat graft + NSF ± rigid fixation for high-grade leaks.
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Affiliation(s)
- Edward C Kuan
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Frederick Yoo
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Pratik B Patel
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Brooke M Su
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Marvin Bergsneider
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
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47
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Chabot JD, Patel CR, Hughes MA, Wang EW, Snyderman CH, Gardner PA, Fernandez-Miranda JC. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2017; 128:1463-1472. [PMID: 28731395 DOI: 10.3171/2017.2.jns161582] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | - Chirag R Patel
- 2Department of Otolaryngology, Loyola University School of Medicine, Chicago, Illinois
| | | | - Eric W Wang
- 4Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Carl H Snyderman
- 4Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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48
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Kerr EE, Jamshidi A, Carrau RL, Campbell RG, Filho LFD, Otto BA, Prevedello DM. Indocyanine Green Fluorescence to Evaluate Nasoseptal Flap Viability in Endoscopic Endonasal Cranial Base Surgery. J Neurol Surg B Skull Base 2017; 78:408-412. [PMID: 28875119 DOI: 10.1055/s-0037-1602777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 03/24/2017] [Indexed: 01/01/2023] Open
Abstract
Objectives The pedicled nasoseptal flap (NSF) has dramatically reduced postoperative cerebrospinal fluid leakage following endoscopic endonasal approach (EEA) surgery. Although rare, its arterial supply may be damaged during harvest or may be preoperatively damaged for numerous reasons. Early recognition permits harvesting a contralateral flap before sacrificing its pedicle as part of the surgical exposure or use of an alternative flap. Design Technical feasibility study and case series. Setting Tertiary care university-associated medical center. Participants Five patients requiring an EEA with NSF reconstruction. Main Outcome Measures During NSF harvest, intravenous indocyanine green (IVICG) was administered, and a customized endoscopic system was used to visualize the emerging fluorescence. At the end of each case, just before final positioning of the NSF, additional IVICG was administered, and the custom endoscope was again introduced to evaluate fluorescence. Results In four patients, the entire NSF fluoresced brightly with IVICG on initial harvest and before final positioning. One patient showed heterogeneous fluorescence of the pedicle and distal parts of the NSF at both stages. All NSFs healed well without complication. Conclusion IVICG facilitates real-time evaluation NSF's arterial supply. This may provide early recognition of arterial compromise, allowing the harvest of alternate flaps or modification of surgery.
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Affiliation(s)
- Edward E Kerr
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Ali Jamshidi
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Ricardo L Carrau
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Raewyn G Campbell
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Leo F Ditzel Filho
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Bradley A Otto
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States.,Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, United States
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49
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Fnais N, Maio SD, Edionwe S, Zeitouni A, Sirhan D, Valdes CJ, Tewfik MA. Hemi-transseptal Approach for Pituitary Surgery: A Follow-Up Study. J Neurol Surg B Skull Base 2017; 78:145-151. [PMID: 28321378 PMCID: PMC5357214 DOI: 10.1055/s-0036-1593816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/13/2016] [Indexed: 10/20/2022] Open
Abstract
Objectives The hemi-transseptal (Hemi-T) approach was developed to overcome the potential drawbacks of the nasoseptal flap (NSF) in endoscopic endonasal transsphenoidal skull base surgery. In this study, we describe further refinements on the Hemi-T approach, and report long-term outcomes as compared with traditional methods of skull base reconstruction. Design A retrospective case-control study. Setting Montreal Neurological Institute and Jewish General Hospital, Montreal, Canada. Participants Patients who underwent endoscopic endonasal transsphenoidal approach to skull base pathology. Main Outcome Measures Operative time, CSF rhinorrhea, and postoperative nasal morbidity. Results A total of 105 patients underwent the Hemi-T approach versus 40 controls. Operative time was shorter using the Hemi-T technique (180.51 ± 56.9 vs. 202.9 ± 62 minutes; p = 0.048). The rates of nasal morbidity (septal perforation [5/102 vs. 6/37; p = 0.029] and mucosal adhesion [11/102 vs. 10/39 p = 0.027]), fascia lata harvest (21/100 vs. 18/39; p = 0.0028), and postoperative CSF leak rates (7/100 vs. 9/38; p = 0.006) were lower in the Hemi-T group. Conclusion Advantages of the Hemi-T approach over traditional exposure techniques include preservation of the nasal vascular pedicle, shorter operative time, reduced fascia lata harvest rates, and decreased nasal morbidity.
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Affiliation(s)
- Naif Fnais
- Department of Otolaryngology—Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Canada
| | | | - Susan Edionwe
- This author is currently working as Allergy and ENT Associate in Sugar Land, Texas, United States
| | - Anthony Zeitouni
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Canada
| | - Denis Sirhan
- Department of Cerebrovascular and Skull Base Surgery, Montreal Neurological Institute, McGill University, Montreal, Canada
| | - Constanza J. Valdes
- Department of Otolaryngology—Head and Neck Surgery, Universidad de Chile, Santiago, Chile
| | - Marc A. Tewfik
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Canada
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50
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Upadhyay S, Buohliqah L, Dolci RLL, Otto BA, Prevedello DM, Carrau RL. Periodic olfactory assessment in patients undergoing skull base surgery with preservation of the olfactory strip. Laryngoscope 2017; 127:1970-1975. [PMID: 28349579 DOI: 10.1002/lary.26546] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/07/2017] [Accepted: 01/26/2017] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Smita Upadhyay
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A
| | - Lamia Buohliqah
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A
| | - Ricardo L L Dolci
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A
| | - Bradley A Otto
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A.,Neurosurgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A.,Neurosurgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A.,Neurosurgery, Wexner Medical Center at Ohio State University, Columbus, Ohio, U.S.A
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