Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks

2012 ◽  
Vol 2 (5) ◽  
pp. 397-401 ◽  
Author(s):  
Jean Anderson Eloy ◽  
Arjuna B. Kuperan ◽  
Osamah J. Choudhry ◽  
Sanaz Harirchian ◽  
James K. Liu
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Nasoseptal Flap ◽  
Csf Diversion ◽  
Skull Base Defects ◽  
Csf Leaks

scholarly journals Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

2019 ◽  
Vol 81 (06) ◽  
pp. 645-650
Author(s):  
Roshni V. Khatiwala ◽  
Karthik S. Shastri ◽  
Maria Peris-Celda ◽  
Tyler Kenning ◽  
Carlos D. Pinheiro-Neto
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Fascia Lata ◽  
High Flow ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Csf Diversion ◽  
Csf Leaks

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/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). 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.

scholarly journals Assessment of Mucocele Formation after Endoscopic Nasoseptal Flap Reconstruction of Skull Base Defects

2013 ◽  
Vol 4 (1) ◽  
pp. ar.2013.4.0050 ◽  
Author(s):  
Qasim Husain ◽  
Saurin Sanghvi ◽  
Olga Kovalerchik ◽  
Pratik A. Shukla ◽  
Osamah J. Choudhry ◽  
...  
Keyword(s):  
Skull Base ◽  
Demographic Data ◽  
Cranial Base ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Inherent Risk ◽  
Defect Site ◽  
Skull Base Defects ◽  
Csf Leaks

Advances in endoscopic skull base (SB) surgery have led to the resection of increasingly larger cranial base lesions, resulting in large SB defects. These defects have initially led to increased postoperative cerebrospinal fluid (CSF) leaks. The development of the vascularized pedicled nasoseptal flap (PNSF) has successfully reduced postoperative CSF leaks. Mucocele formation, however, has been reported as a complication of this technique. In this study, we analyze the incidence of mucocele formation after repair of SB defects using a PNSF. A retrospective review was performed from December 2008 to December 2011 to identify patients who underwent PNSF reconstruction for large ventral SB defects. Demographic data, defect site, incidence of postoperative CSF leaks, and rate of mucocele formation were collected. Seventy patients undergoing PNSF repair of SB defects were identified. No postoperative mucocele formation was noted at an average radiological follow-up of 11.7 months (range, 3–36.9 months) and clinical follow-up of 13.8 months (range, 3–38.9 months), making the overall mucocele rate 0%. The postoperative CSF leak rate was 2.9%. Proper closure of SB defects is crucial to prevent CSF leaks. The PNSF is an efficient technique for these repairs. Although this flap may carry an inherent risk of mucocele formation when placed over mucosalized bone during repair, we found that meticulous and strategic removal of mucosa from the site of flap placement resulted in a 0% incidence of postoperative mucocele formation in our cohort.

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

2016 ◽  
Vol 3 (1) ◽  
pp. 71 ◽  
Author(s):  
Shibu George ◽  
Sandeep Suresh
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Middle Turbinate ◽  
Benign Intracranial Hypertension ◽  
Nasoseptal Flap ◽  
Csf Rhinorrhea ◽  
Endoscopic Closure ◽  
Mucoperiosteal Flap ◽  
Skull Base Defects

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

scholarly journals Minimally invasive endoscopic repair of refractory lateral skull base cerebrospinal fluid rhinorrhea: case report and review of the literature

2018 ◽  
Vol 44 (3) ◽  
pp. E8 ◽  
Author(s):  
Brandon Lucke-Wold ◽  
Erik C. Brown ◽  
Justin S. Cetas ◽  
Aclan Dogan ◽  
Sachin Gupta ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Minimally Invasive ◽  
Skull Base ◽  
Congenital Defects ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Lateral Skull Base ◽  
Csf Diversion ◽  
Csf Leaks

Cerebrospinal fluid (CSF) leaks occur in approximately 10% of patients undergoing a translabyrinthine, retrosigmoid, or middle fossa approach for vestibular schwannoma resection. Cerebrospinal fluid rhinorrhea also results from trauma, neoplasms, and congenital defects. A high degree of difficulty in repair sometimes requires repetitive microsurgical revisions—a rate of 10% of cases is often cited. This can not only lead to morbidity but is also costly and burdensome to the health care system. In this case-based theoretical analysis, the authors summarize the literature regarding endoscopic endonasal techniques to obliterate the eustachian tube (ET) as well as compare endoscopic endonasal versus open approaches for repair. Given the results of their analysis, they recommend endoscopic endonasal ET obliteration (EEETO) as a first- or second-line technique for the repair of CSF rhinorrhea from a lateral skull base source refractory to spontaneous healing and CSF diversion. They present a case in which EEETO resolved refractory CSF rhinorrhea over a 10-month follow-up after CSF diversions, wound reexploration, revised packing of the ET via a lateral microscopic translabyrinthine approach, and the use of a vascularized flap had failed. They further summarize the literature regarding studies that describe various iterations of EEETO. By its minimally invasive nature, EEETO imposes less morbidity as well as less risk to the patient. It can be readily implemented into algorithms once CSF diversion (for example, lumbar drain) has failed, prior to considering open surgery for repair. Additional studies are warranted to further demonstrate the outcome and cost-saving benefits of EEETO as the data until now have been largely empirical yet very hopeful. The summaries and technical notes described in this paper may serve as a resource for those skull base teams faced with similar challenging and otherwise refractory CSF leaks from a lateral skull base source.

Posterior nasoseptal flap in the reconstruction of skull base defects following endonasal surgery

2019 ◽  
Vol 133 (05) ◽  
pp. 380-385
Author(s):  
C Singh ◽  
N Shah
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Cerebrospinal Fluid Leak ◽  
High Flow ◽  
Anterior Skull Base ◽  
Nasoseptal Flap ◽  
Lumbar Drain ◽  
Endonasal Reconstruction ◽  
Skull Base Defects ◽  
Fluid Leak

AbstractObjectiveTo study the clinical outcomes of a posterior nasoseptal flap used in the endonasal reconstruction of anterior skull base defects.MethodsThe early harvested flap was used to reconstruct anterior skull base defects in patients with high-flow on-table cerebrospinal fluid leak. Post-operatively, the patients were analysed for cerebrospinal fluid leak and bleeding.ResultsOf the 100 patients, 87 had macro defects while 13 had micro defects. Non-secretary lesions were present in 60 patients, while secretary lesions were present in 40 patients. Cerebrospinal fluid leak was present in all the patients undergoing surgery, and the majority of them had a lumbar drain fitted. Post-operatively, two patients experienced bleeding and only two patients had a cerebrospinal fluid leak.ConclusionThe use of a posterior nasoseptal flap for reconstruction of the anterior skull base amongst patients with a high-flow intra-operative cerebrospinal fluid leak can help prevent post-operative cerebrospinal fluid leak. Its applicability to wide patient profiles, with respect to age, size of defect and diagnosis, make it a versatile choice for reconstruction after endonasal anterior skull base surgical procedures.

From research to clinical practice: long-term impact of randomized clinical trial examining the effect of lumbar drains on cerebrospinal fluid leak rates following endonasal skull base surgery.

2021 ◽  
Author(s):  
Philippe Lavigne ◽  
paul gardner ◽  
Eric W Wang ◽  
Carl H. Snyderman
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Controlled Trial ◽  
Posterior Cranial Fossa ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Increased Risk ◽  
Cranial Fossa ◽  
Csf Diversion ◽  
Csf Leaks

Intraoperative cerebrospinal fluid (CSF) leaks are associated with increased risk of post-operative CSF leaks despite multilayered reconstruction with vascularized tissue. A recent randomized controlled trial (RCT) examining the use of peri-operative lumbar drains (LD) in high-risk skull base defects identified a significant reduction in post-operative CSF leak incidence (21.2% vs. 8.2%; p=0.017). This study was conducted to assess the efficacy of the selective use of CSF diversion, for patients with intraoperative CSF leaks involving endoscopic endonasal approaches (EEA) to the skull base. Method: Consecutive endoscopic endonasal surgeries of the skull base from a pre-RCT cohort and post-RCT cohort were compared. The following case characteristics between the two cohorts were examined: patient age, body mass index (BMI), rate of revision surgery, tumor histology, use of CSF diversion, and vascularized reconstruction. The primary measured outcome was post-operative CSF leak. Results: The pre-RCT cohort included 76 patients and the post-RCT cohort, 77 patients, with dural defects in either the anterior or posterior cranial fossa (pituitary and parasellar/suprasellar surgeries excluded). There was a significant reduction in the incidence of post-operative CSF leak in the post-RCT cohort (27.6% vs. 12.9%; p=0.04). On subgroup analysis, there was a trend toward improvement in CSF leak rate of the anterior cranial fossa (19.2% vs 10.5%; p=0.27) whereas CSF leak rates of the posterior cranial fossa were significantly reduced compared to the pre-RCT cohort (41.4% vs 12.8%; p=0.02). Conclusion This study demonstrates that the integration of selective CSF diversion into the reconstructive algorithm improved post-operative CSF leak rates.

scholarly journals Pediatric skull base reconstruction: case report of a tunneled temporoparietal fascia flap

2016 ◽  
Vol 17 (3) ◽  
pp. 371-377 ◽  
Author(s):  
Jeffrey C. Rastatter ◽  
Patrick C. Walz ◽  
Tord D. Alden
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Cerebrospinal Fluid Leak ◽  
Nasoseptal Flap ◽  
Pediatric Case ◽  
Clival Chordoma ◽  
Temporoparietal Fascia ◽  
Temporoparietal Fascia Flap ◽  
Fluid Leak ◽  
Fascia Flap

The authors of this report present a pediatric case involving the use of a tunneled temporoparietal fascia flap to reconstruct a skull base defect for a multiply recurrent clival chordoma and cerebrospinal fluid leak, demonstrate the surgical technique through illustrations and intraoperative photos, and review the pertinent literature. A 9-year-old female patient underwent extensive clival chordoma resection via both the endoscopic and open approaches, which ultimately exhausted the bilateral nasoseptal flaps and other intranasal reconstructive options. Following proton beam radiation and initiation of chemotherapy, tumor recurrence was managed with further endoscopic resection, which was complicated by a recalcitrant cerebrospinal fluid leak. A tunneled temporoparietal fascia flap was used to provide vascular tissue to augment an endoscopic repair of the leak and reconstruction of the skull base. While the nasoseptal flap remains the workhorse for many pediatric and adult endoscopic skull base reconstructions, the tunneled temporoparietal fascia flap has a demonstrated efficacy in adults when the nasoseptal flap and other intranasal flaps are unavailable. This report documents a pediatric case, serving as a step toward establishing this technique in the pediatric population.

Extradural cartilage inlay graft in cerebrospinal fluid fistula repair

2010 ◽  
Vol 124 (12) ◽  
pp. 1294-1297 ◽  
Author(s):  
P Thulasi Das ◽  
D Balasubramanian
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Success Rate ◽  
Bony Defect ◽  
Cerebrospinal Fluid Fistula ◽  
Fistula Repair ◽  
Cerebrospinal Fluid Rhinorrhoea ◽  
Skull Base Defects ◽  
Fluid Fistula

AbstractObjective:To present our experience in managing cerebrospinal fluid rhinorrhoea using the cartilage inlay (underlay) technique to repair skull base defects larger than 4 mm.Study design:Retrospective study involving patients presenting with cerebrospinal fluid rhinorrhoea between 1994 and 2008.Setting:Patients were treated in a tertiary referral centre for nose and sinus diseases. Patients' medical records were reviewed and analysed.Results:A total of 62 patients were operated upon using a cartilage inlay technique to repair bony skull base defects ranging in size from 4 to 20 mm (widest diameter). Of these 62 patients, 16 constituted revisions of earlier procedures undertaken elsewhere. The success rate of the technique was 100 per cent. Patient follow up ranged from six months to 16 years, with a median follow up of 15 months. Three patients had minor post-operative sinus infections; no serious complications were encountered.Conclusion:Extradural cartilage inlay appears to be an effective technique in the management of cerebrospinal fluid rhinorrhoea, especially for large defects and revision procedures. To our knowledge, the described patients represent the largest reported series of cerebrospinal fluid rhinorrhoea cases managed using the cartilage inlay technique. We believe that the crucial factors in our high success rate for cerebrospinal fluid fistula repair are: precise identification of the bony defect; meticulous preparation of the graft bed; careful elevation of the dura; judicious use of just enough graft tissue; and adequate graft support.

Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Post-Operative Period Following Pituitary and Ventral Skull Base Surgery

2021 ◽  
Author(s):  
Peter A. Benedict ◽  
Joseph R. Connors ◽  
Micah R. Timen ◽  
Nupur Bhatt ◽  
Richard Lebowitz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Postoperative Period ◽  
Skull Base Surgery ◽  
Tertiary Care ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Predictive Values ◽  
Ventral Skull Base ◽  
Csf Leaks

Objective: Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design: Retrospective chart review Setting: Tertiary care center Methods and Participants: All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017–March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intra-operative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures: Specificity and safety of ITF Results: Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50±11.89. There were 6 patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100% and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions: Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. Intrathecal fluorescein represents a specific and safe test with potential utility in the postoperative setting.

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