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Features of the use of vascularized flaps for plastics of skull base defects after removal of meningoencephalocele in children
Abstract
Basal meningoencephalocele is a rare pathology that occurs due to the prolapse of meninges and brain tissues through a bone defect in the skull base. Treatment of patients with this pathology consists in the removal of the meningoencephalocele, followed by plasty of the skull base defect. One of the ways to close defects of the skull base is to use vascularized flaps. Vascularized flaps are the method of choice of plastic material in adults, however, in pediatric practice, there is insufficient data on the effectiveness and safety of their use. Purpose: to assess the effectiveness and safety of the use of vascularized flaps in the removal of meningoencephalocele, as well as to clarify the indications for their use in pediatric practice Material and methods. A retrospective analysis of a series of patients with basal meningoencephalocele aged 0 to 18 years, operated from 2008 to 2020. Comparison of two groups, divided according to the types of methods used for plastics of skull base defects, has been carried out. Results. There was a statistically significant difference in the groups for the localization of defects (p = 0.048), complaints in the postoperative period for pain in the wound on the left hip (p < 0.001). There was no statistically significant difference in the groups in terms of the size of the defect (p = 1), the frequency of using lumbar drainage (p = 0.141), the duration of surgery (p = 0.2), and blood loss (p = 0.248). Conclusions. Vascularized flaps are effective for plasty of the skull base defect in children in the removal of meningoencephalocele. The safety of using flaps intraoperatively and in the early postoperative period has been proved. The question of the long-term results and the influence of the formation of a vascularized flap on the structures of the facial skeleton remains unstudied. When planning the elimination of meningoencephalocele in children and the choice of plastic material, it is necessary to take into account the localization of the fistula.
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Introduction
The repair of skull base defects after skull base surgeries is a major problem. Postoperative cerebrospinal fluid leak in reconstruction of the anterior skull base defect using a nasal septal flap was minimal when compared with other techniques. The nasal septal flap should be considered as the first line of treatment after transnasal endoscopic skull base surgery.
Objectives
Evaluation of the usefulness and reliability of endoscopic endonasal skull base reconstruction using a nasal septal flap.
Patients and methods
This study was carried out on 10 paediatric patients with skull base defects because of different pathologies. These patients were admitted in El-Kasr El-Ainy Hospital, Otorhinolaryngology Department. These patients included one patient with a germ cell tumour, five patients with a congenital encephalocele and four patients with skull base defects because of trauma to the skull base.
Results and conclusion
Various endoscopic techniques have been described to separate the cranial cavity from the sinonasal cavity to prevent infection, pneumocephalus and cerebrospinal fluid leak. Different techniques were used to close the anterior skull base defects such as multilayer free graft, suturing the dural defect combined with free graft and reconstruction based on a vascularized graft. The nasal septal flap should be considered as the first line of treatment after transnasal endoscopic skull base resections.
PurposeTo retrospectively analyse surgical management of clinico-radiologically proven nasal meningoencephalocele amongst children and results of repair with single-layer septo-mucosal flap at a tertiary skull base surgery centre in north India.Methods
Fifteen children with clinic-radiological nasal meningoencephaloceles with or without CSF rhinorrhoea were included. Radiological scans included CT scans and MRI scans for all cases to delineate soft tissue and bony architecture. All children underwent endoscopic excision of encephaloceles and repair of the skull base defect.ResultsThe authors were successful in fourteen cases. Successful cases included 4 children less than 6 months of age who underwent single-layer rotated septo-mucosal flaps, thereby avoiding donor site morbidity.Conclusion
As endoscopic excision of nasal encephalocele is an established management approach, the authors take the concept of minimally invasive surgery a step further by successfully managing these lesions with single-layer repair. Vascularized septo-mucosal flap seems to be the only determining factor for a successful repair for congenital meningoencephalocele. However, a prospective study comprising a larger subset of patients would substantiate the assumption.
Endonasal endoscopic approach (EEA) has become a routine and effective method for the management of large skull base defects in adults and increasingly in older pediatric populations despite their challenging narrow transnasal corridors. To our knowledge, this is the first report in the literature of a large craniopharyngeal canal (CC) meningoencephalocele in a 6-month-old infant managed purely through EEA, also by utilizing a pedicled nasoseptal flap (PNF).
Introduction
Benign lesions of the skull base are common in the paediatric population, and are usually congenital in aetiology. Majority of these lesions are treated transcranially exposing the patients to a number of risks. Although endoscopic endonasal surgery (EES) helps avoid many of these potential morbidities, CSF leak with its attendant complication remains a big concern. This study reports the use of the Hadad flap in the reconstruction of skull base defects in infants to prevent this problem. The study was conducted on four infants with a mean age of 7 months, who underwent repairs for CSF leaks associated with congenital lesions like meningocele or meningoencephalocele, using the Hadad flap. Of the four patients, three cases were revision cases and one was primary where the patients presented with complaints such as nasal obstruction and watery nasal discharge. Post surgery, the infants were monitored for a mean period of 23 months and no major complications or recurrent CSF drainage were observed. Minor complications that were observed include vestibulitis and crusting in the nose. The utility of the Hadad flap in the reconstruction of skull base defects in the paediatric age group has been controversial while its utility in infants has not been studied in literature so far. We report here in our series four infant patients in whom we believe that the nasal septum and the skull base will develop proportionally to each other, hence lowering the chances of a short flap and eliminating the occurrence of future complications.
Conclusion
The nasoseptal flap is an effective and safe technique for reconstructing skull base defects in infancy. It can be concluded that this technique does not have any potential effect on septal or craniofacial growth as the flap is harvested only on one side with normal mucosal cover on the other side. There is no posterior septectomy or any form of bony or cartilaginous resection that is performed, hence avoiding any effects on bony growth. No studies have been published in literature so far and to the best of our knowledge, this is the first report describing the efficacy of the nasoseptal flap in infants.
Introduction
Congenital meningoencephaloceles represent a rare clinical entity, with its frequency being around 1 out of 4000–5000 live births. They usually present as a midline mass and the differential diagnosis includes dermoids, encephaloceles, and gliomas. Although the standard coronal approach with frontal craniotomy and pericranial flap has been considered the preferred method for several years, it is associated with risks and prolonged hospitalization. The endoscopic procedure is gaining ground and we are aiming to present our experience from five cases that were treated endoscopically.
Materials and methods
Five cases of paediatric meningoencephaloceles (age ranging from 2.5 to 10 years) were treated in our department between the years 2007–2017. Four children had a congenital and one child a post-traumatic meningoencephalocele. The presenting symptoms included nasal obstruction, meningitis and CSF leak. All patients had pre-operative imaging with CT and MRI scans and the preferred method of repair was multi-layered closure.
Results
All our patients had uneventful recovery, without any post-operative complications. The follow-up period ranges from 39 to 98 months. All five patients remain asymptomatic and recurrence-free.
Conclusion
Endoscopic management of paediatric meningoencephaloceles is a reliable and safe approach and it is known to have no adverse effects on facial growth. It carries a satisfactory success rate, reduces the in-hospital stay with lower cost of treatment, better cosmesis and lower morbidity than external procedures. It requires multidisciplinary team setting in a tertiary centre with experienced endoscopic anterior skull base surgeons. Pre-operative assessment and post-operative care are of paramount importance and larger series need to be studied to reach safe conclusions and establish management guidelines.
Introduction:
Encephaloceles in relation to the nose are rare lesions affecting the skull base. In the pediatric population, majority are congenital lesions manifesting as nasal masses requiring surgical intervention.
Materials and methods:
A retrospective study of 6 consecutive patients below 12 years of age with intranasal meningoencephalocele treated by endonasal endoscopic approach at our tertiary centre was done. The follow up period ranged from 6 months to 2 years. A detailed clinical and radiological evaluation of these cases was done. Endonasal endoscopic repair (gasket seal/fat plug) was carried out in all cases.
Results:
Out of 6 patients, 4 patients had post-traumatic and rest 2 cases had congenital meningo-encephaloceles. All patients were asymptomatic in post-operative follow up period. One patient had minor complication of nasal alar collapse due to intra-operative adherence of encephalocele to cartilaginous framework.
Conclusion:
Transnasal endoscopic repair of anterior skull base meningoencephalocele is a minimally invasive single stage surgery, and has advantage in terms of lesser hospital stay, cost of treatment, and better cosmesis. The repair technique should be tailored to the size of defect to provide a water-tight seal for better outcome.
Objective
The influence of graft type (non-autologous versus autologous) on surgical outcomes in endoscopic anterior skull base (EASB) reconstruction is not well-understood. This review systematically evaluated rates of post-operative complications of EASB repairs that utilized autologous or non-autologous grafts.
Methods
Original studies reporting EASB reconstruction outcomes were extracted from PubMed, Ovid, and Cochrane Library from database inception to 2019. Risk ratios (RRs), risk differences (RDs), chi-square tests, and multivariate logistic regression were used to evaluate outcome measures: post-operative CSF leaks, meningitis, and other major complications (OMCs).
Results
A total of 2275 patients from 29 studies were analyzed. Rates of post-operative CSF leaks, meningitis, and OMCs were 4.0%, 1.6%, and 2.3%, respectively, using autologous grafts and 5.0%, 0.3%, and 1.0%, respectively, using non-autologous grafts. Multivariate analysis of 118 patients demonstrated no significant differences in age, CSF flow rate, single or multilayer reconstruction, and presence of intra-operative CSF leak or lumbar drain. Meta-analyses of six studies yielded a RR of 0.64 (95% CI:0.19-2.14; p=0.47) for post-operative CSF leakage and RDs of -0.01 (95% CI:-0.06-0.05; p=0.80) and -0.02 (95% CI:-0.09-0.05; p=0.51) for post-operative meningitis and OMCs, respectively. There were no significant differences in post-operative CSF leakage (p=0.95) and OMCs (p=0.41) between graft types among cases with intra-operative CSF leaks. However, meningitis rates were lower (p=0.04) in the non-autologous group.
Conclusions
EASB reconstructions utilizing autologous and non-autologous grafts are associated with similar rates of post-operative CSF leakage and OMCs. In cases with intra-operative CSF leakage, non-autologous grafts were associated with reduced post-operative meningitis.
Objectives
Cerebrospinal fluid (CSF) rhinorrhea in children is relatively uncommon. Endoscopic repair techniques in adults have become first line for nasal-based CSF leaks, and this meta-analysis looks at the success rates of CSF leak cessation following endoscopic repair in children.
Methods
Three researchers extracted information involving patient population, surgical technique, outcomes of interest, and study design. A computerized search of MEDLINE, EMBASE and the Cochrane library (January 1990–September 2019) looked for several papers on the subject of CSF leak repair in children using endoscopic technique.
Results
A total of 15 studies met inclusion criteria. Endoscopic repair of CSF rhinorrhea in children shows a pooled weighted success rate of 94% after first attempt. The most common etiology was traumatic followed by congenital. Iatrogenic defects secondary to tumor resection are becoming more common. The high success rate was irrespective of the techniques using.
Conclusion
Endoscopic repair techniques have a highly successful closure rate for children presenting with CSF rhinorrhea.
Background:
Endoscopic endonasal skull base surgery (ESBS) is a well-established management strategy for anterior cranial fossa (ACF) encephaloceles in adults. However, its application to the pediatric population has not been evaluated in large-scale studies. This study systematically reviews the safety of ESBS for pediatric ACF encephaloceles.
Methods:
Articles reporting on pediatric patients undergoing purely ESBS for encephaloceles were reviewed from three databases (PubMed, Scopus, and Cochrane Library). Main outcomes were post-operative cerebrospinal fluid (CSF) leak and other surgical complications.
Results:
Twenty-three articles provided data on 110 eligible patients with a mean age of 4.3 years (range birth - 18 years). Intraoperative CSF leaks occurred in 18.5% of children while post-operative CSF leaks developed in 6.0% of cases. Rates of meningitis and hydrocephalus were each 3.7%. Other complications included alar collapse, nasal stenosis, transient diabetes insipidus, pneumonia, and neurologic injury, collectively occurring in 7.0% of cases. The rate of death was 4.8%. The average duration of follow-up was 25.3 months. Encephaloceles recurred in 5.2% of patients.
Conclusions:
ESBS for pediatric ACF encephaloceles provides a relatively favorable risk-benefit profile, with a low rate of post-operative CSF leak, other surgical complications, and disease recurrence.
Introduction
The endoscopic expanded endonasal approach (EEA) has been shown to be a safe and effective surgical technique in the resection of pediatric skull base lesions. Cerebrospinal fluid (CSF) leaks are among the most common complications of this approach. Here we review skull base resections using EEA in pediatric patients at our single institution, to identify potential risk factors for this surgical complication.
Methods
A retrospective chart review was conducted on pediatric patients at our single institution for patients 19 years-old and under, who underwent an EEA for resection of a skull base tumor.
Results
Thirty-nine pediatric patients (ages 1–19 years) with 8 different tumor pathologies underwent an EEA for resection of their skull base tumors. 21 patients experienced an intraoperative CSF leak, of which 10 (48%) were “high-flow” leaks and 11 (52%) were “low-flow” leaks. Nasoseptal flaps were only used to repair the intraoperative “high flow” leaks (n = 10), and “low flow” and “no leaks” were repaired with allograft and fat. No patients experienced a post-operative CSF leak.
Conclusion
In our pediatric series, the skull base repair algorithm of using an NSF only in cases of “high flow” intraoperative leaks was effective, and no post-operative CSF leaks occurred. Not using an NSF in cases of “low-flow” or “no leak” cases allows for decreased anatomical disruption in the growing patient.
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.
Object:
The proximity of craniopharyngiomas to vital neurovascular structures and their high recurrence rates make them one of the most challenging and controversial management dilemmas in neurosurgery. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for both pediatric and adult craniopharyngiomas. The object of the present study was to present the results of EES and analyze outcome in both the pediatric and the adult age groups.
Methods:
The authors retrospectively reviewed the records of patients with craniopharyngioma who had undergone EES in the period from June 1999 to April 2011.
Results:
Sixty-four patients, 47 adults and 17 children, were eligible for this study. Forty-seven patients had presented with primary craniopharyngiomas and 17 with recurrent tumors. The mean age in the adult group was 51 years (range 28-82 years); in the pediatric group, 9 years (range 4-18 years). Overall, the gross-total resection rate was 37.5% (24 patients); near-total resection (> 95% of tumor removed) was 34.4% (22 patients); subtotal resection (≥ 80% of tumor removed) 21.9% (14 patients); and partial resection (< 80% of tumor removed) 6.2% (4 patients). In 9 patients, EES had been combined with radiation therapy (with radiosurgery in 6 cases) as the initial treatment. Among the 40 patients (62.5%) who had presented with pituitary insufficiency, pituitary function remained unchanged in 19 (47.5%), improved or normalized in 8 (20%), and worsened in 13 (32.5%). In the 24 patients who had presented with normal pituitary function, new pituitary deficit occurred in 14 (58.3%). Nineteen patients (29.7%) suffered from diabetes insipidus at presentation, and the condition developed in 21 patients (46.7%) after treatment. Forty-four patients (68.8%) had presented with impaired vision. In 38 (86.4%) of them, vision improved or even normalized after surgery; in 5, it remained unchanged; and in 1, it temporarily worsened. One patient without preoperative visual problems showed temporary visual deterioration after treatment. Permanent visual deterioration occurred in no one after surgery. The mean follow-up was 38 months (range 1-135 months). Tumor recurrence after EES was discovered in 22 patients (34.4%) and was treated with repeat surgery (6 patients), radiosurgery (1 patient), combined repeat surgery and radiation therapy (8 patients), interferon (1 patient), or observation (6 patients). Surgical complications included 15 cases (23.4%) with CSF leakage that was treated with surgical reexploration (13 patients) and/or lumbar drain placement (9 patients). This leak rate was decreased to 10.6% in recent years after the introduction of the vascularized nasoseptal flap. Five cases (7.8%) of meningitis were found and treated with antibiotics without further complications. Postoperative hydrocephalus occurred in 7 patients (12.7%) and was treated with ventriculoperitoneal shunt placement. Five patients experienced transient cranial nerve palsies. There was no operative mortality.
Conclusions:
With the goal of gross-total or maximum possible safe resection, EES can be used for the treatment of every craniopharyngioma, regardless of its location, size, and extension (excluding purely intraventricular tumors), and can provide acceptable results comparable to those for traditional craniotomies. Endoscopic endonasal surgery is not limited to adults and actually shows higher resection rates in the pediatric population.
Objective: 1) Determine ability to achieve 100% coverage of sellar skull base defects with the vascularized nasal septal flap in pediatric patients. 2) Identify the rate of residual CSF leaks following this repair technique in these pediatric patients. 3) Review the demographics and perioperative course in these children. Method: Study design: Retrospective case series. Study conducted: January 1, 2006, to January 1, 2012. Condition studied: Repair of skull base defects after resection of sellar lesions. Subjects: Children. Setting: Children's hospital. Intervention: Endonasal repair of skull base defects with a vascularized nasoseptal flap. Outcome measurement(s): 1) Complete coverage of defect. 2) Postoperative CSF leak. Results: Demographics: Ten children were identified, and 11 flaps were performed. The average patient age was 12.6 years old (range of 5.1-17.4 years). Total coverage was achieved in all cases. The technique was particularly challenging in the younger patients. A brisk CSF leak was observed during closure in 3 cases, but no CSF leaks were observed after balloon packing removal (day 5). No lumbar drains were used. Only minor complications were observed. A second look with debridement of packing material due to poor cooperation with office endoscopy was done in 7 children (70%). Conclusion: The endonasal vascularized nasal septal flap is a feasible and reliable method of repair of dural defects after resection of sellar lesions in children. Despite active CSF leak in 3 children, there were no residual CSF leaks. Unlike adult patients, children may require operative nasal debridement after repair has healed.
© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2012.
Object:
The use of endoscopic endonasal surgery (EES) for skull base pathologies in the pediatric population presents unique challenges and has not been well described. The authors reviewed their experience with endoscopic endonasal approaches in pediatric skull base surgery to assess surgical outcomes and complications in the context of presenting patient demographics and pathologies.
Methods:
A retrospective review of 133 pediatric patients who underwent EES at our institution from July 1999 to May 2011 was performed.
Results:
A total of 171 EESs were performed for skull base tumors in 112 patients and bony lesions in 21. Eighty-five patients (63.9%) were male, and the mean age at the time of surgery was 12.7 years (range 2.3-18.0 years). Skull base tumors included angiofibromas (n = 24), craniopharyngiomas (n = 16), Rathke cleft cysts (n = 12), pituitary adenomas (n = 11), chordomas/chondrosarcomas (n = 10), dermoid/epidermoid tumors (n = 9), and 30 other pathologies. In total, 19 tumors were malignant (17.0%). Among patients with follow-up data, gross-total resection was achieved in 16 cases of angiofibromas (76.2%), 9 of craniopharyngiomas (56.2%), 8 of Rathke cleft cysts (72.7%), 7 of pituitary adenomas (70%), 5 of chordomas/chondrosarcomas (50%), 6 of dermoid/epidermoid tumors (85.7%), and 9 cases of other pathologies (31%). Fourteen patients received adjuvant radiotherapy, and 5 received chemotherapy. Sixteen patients (15.4%) showed tumor recurrence and underwent reoperation. Bony abnormalities included skull base defects (n = 12), basilar invagination (n = 4), optic nerve compression (n = 3) and trauma (n = 2); preexisting neurological dysfunction resolved in 12 patients (57.1%), improved in 7 (33.3%), and remained unchanged in 2 (9.5%). Overall, complications included CSF leak in 14 cases (10.5%), meningitis in 5 (3.8%), transient diabetes insipidus in 8 patients (6.0%), and permanent diabetes insipidus in 12 (9.0%). Five patients (3.8%) had transient and 3 (2.3%) had permanent cranial nerve palsies. The mean follow-up time was 22.7 months (range 1-122 months); 5 patients were lost to follow-up.
Conclusions:
Endoscopic endonasal surgery has proved to be a safe and feasible approach for the management of a variety of pediatric skull base pathologies. When appropriately indicated, EES may achieve optimal outcomes in the pediatric population.
Background:
Repair of anterior skull base cerebrospinal fluid (CSF) leaks, encephaloceles, and meningoceles can prevent meningitis, intracranial abscess, and pneumocephalus. Various surgical techniques have been employed for repair, including open transcranial and transfacial methods. The endoscopic endonasal approach represents a minimal access but equally aggressive alternative. We conducted a systematic review of case series and case reports to assess the role of endoscopy in the management of these lesions.
Methods:
We performed a MEDLINE search of the literature (1950-2010) to identify open and endoscopic surgical series for repair of anterior skull base CSF leaks, encephaloceles, and meningoceles. Comparisons were made for patient and defect characteristics as well as success of repair, morbidity, and outcome.
Results:
Seventy-one studies, involving 1178 patients, were included. There was no significant difference in the rate of successful repair (~90%) between the open and endoscopic cohorts. Compared with open approaches, complications were significantly lower in the endoscopic group, including meningitis (3.9% versus 1.1%, p = 0.034), abscess/wound infection (6.8% versus 0.7%, p < 0.001), and sepsis (3.8% versus 0%, p = 0.003). Perioperative mortality was also lower in the endoscopic group (0%) compared with the open group (1.4%) (p < 0.001).
Conclusion:
Our systematic review supports the endoscopic endonasal approach as a safe and effective alternative for the treatment of anterior skull base defects, which may be preferable in select patients.
Background:
In patients with large dural defects of the anterior and ventral skull base after endonasal skull base surgery, there is a significant risk of a postoperative cerebrospinal fluid leak after reconstruction. Reconstruction with vascularized tissue is desirable to facilitate rapid healing, especially in irradiated patients.
Methods:
We developed a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery (Hadad-Bassagasteguy flap [HBF]). A retrospective review of patients undergoing endonasal skull base surgery at the University of Rosario, Argentina, and the University of Pittsburgh Medical Center was performed to identify patients who were reconstructed with a vascularized septal mucosal flap.
Results:
Forty-three patients undergoing endonasal cranial base surgery were repaired with the septal mucosal flap. Two patients with postoperative cerebrospinal fluid leaks (5%) were successfully treated with focal fat grafts. We encountered no infectious or wound complications in this series of patients. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with electrocautery and the flap blood supply was preserved.
Conclusion:
The HBF is a versatile and reliable reconstructive technique for defects of the anterior, middle, clival, and parasellar skull base. Its use has resulted in a sharp decrease in the incidence of postoperative cerebrospinal fluid leaks after endonasal skull base surgery and is recommended for the reconstruction of large dural defects and when postoperative radiation therapy is anticipated.
Over the past 10 years, significant anatomic, technical, and instrumentation advances have facilitated the exposure and resection of intradural lesions via a fully endoscopic expanded endonasal approach (EEA). The vascularized nasoseptal flap (based on the posterior nasoseptal artery) has become our primary endoscopic reconstructive technique. The goals of this study are to prospectively evaluate the nasoseptal flap and high-risk cerebral spinal fluid (CSF) leak variables.
Prospective evaluation was performed of EEA patients with intraoperative high-flow leaks (either a cistern or ventricle open to nasal cavity during tumor dissection) who underwent nasoseptal flap reconstruction.
Seventy consecutive nasoseptal flaps for high-flow intraoperative leaks were evaluated prospectively by the primary author. Twelve risk factors were then graded at the time of the operations and correlated to CSF leak outcomes. The overall postoperative CSF leak rate was 5.7% (4/70). All four postoperative leaks were successfully managed with endoscopic repair and CSF diversion. A multivariate analysis of all 12 risk factors is detailed. Pediatric patients, large dural defects, and radiation therapy were noted to be factors in reconstructive failure. One flap death occurred in a patient with prior surgery and proton therapy, this leak was managed with a temporoparietal flap and endonasal repair.
The nasoseptal flap is an excellent anterior skull base reconstructive technique. Patients with high-flow intraoperative CSF leaks had a 94% successful reconstruction rate. Patients with skull base proton radiation therapy are at higher risk for flap failure and preparation for nonradiated tissue reconstruction should be discussed with the patient.
A prospective study of endoscopic expanded endonasal approaches (EEA) with nasoseptal flap reconstructions revealed anecdotal evidence of less available relative septal length in pediatric patients. Our goal is to use radioanatomic analysis of computed tomography (CT) scans to determine limitations of the nasoseptal flap in pediatric skull base reconstruction and to describe clinical outcomes after using the nasoseptal flap in six pediatric patients.
Six pediatric patients who underwent EEA with nasoseptal flap reconstruction were prospectively analyzed for flap coverage and postoperative cerebrospinal fluid (CSF) leak. Fifty maxillofacial CTs of individuals <18 years of age and 10 adult images underwent radioanatomic analysis.
Measurements included potential nasoseptal flap dimensions and dimensions required to reconstruct an anterior skull base defect, a trans-sellar defect, and a transclival defect. Measurements were compared to determine if flap size would be sufficient to cover independent EEA defects within different age groups.
Two out of three patients <14 years of age had inadequate flap coverage; one had a postoperative CSF leak. Patients >14 years of age had adequate flap coverage. Average potential flap length is less than average anterior skull base length until age 9 years to 10 years, and less than average trans-sellar defect length until age 6 years to 7 years. Septal growth is most rapid between 10 years and 13 years.
: The pedicled nasoseptal flap may not be a viable option for EEA reconstruction in children <10 years of age. This flap is a reliable option in patients >14 years of age, as their septums are comparable to adults. Patients 10 years to 13 years of age require careful consideration of facial analysis and preoperative radioanatomic evaluation on an individual basis. Laryngoscope, 2009.
One of the major challenges of cranial base surgery is reconstruction of the dural defect. Following a craniofacial resection, the standard reconstructive technique is direct suture repair of the dural defect with a fascial graft and rotation of an anteriorly based pericranial scalp flap to cover the dura. The introduction of endoscopic techniques and an endonasal approach to the ventral skull base has created new challenges for reconstruction. The nasoseptal flap has become the workhorse for vascularized endoscopic skull base reconstruction; however at times, the septal mucosal flap may be unavailable for reconstruction. This can be due to prior surgical resection or involvement of the nasal septum by sinonasal cancer. We have developed a minimally invasive endoscopic pericranial flap for endoscopic skull base reconstruction. The use of a pericranial scalp flap for reconstruction during endonasal skull base surgery using minimally invasive techniques has not been previously reported.
We performed cadaveric studies to illustrate feasibility of an endoscopic pericranial flap for endonasal skull base reconstruction, then applied this novel technique to an elderly patient after endonasal skull base and dural resection of an esthesioneuroblastoma.
The technical report of the minimally invasive pericranial flap is outlined and the advantages and limitations during endonasal skull base reconstruction are discussed. The patient had excellent healing of her skull base and had no evidence of any postoperative cerebrospinal fluid leak.
The minimally invasive endoscopic pericranial flap provides another option for endonasal reconstruction of cranial base defects. There is minimal donor site morbidity, and it provides a large flap that can cover the entire ventral skull base. The issues of intranasal tissue tumor involvement and the need for radiotherapy make the endoscopic pericranial flap an ideal reconstruction for anterior cranial base defects resulting from endonasal sinonasal and skull base cancer resections.
The objective of this paper is to present a case of a 2-year-old girl diagnosed with a meningo-encephalocele after episodes of meningitis, and treated with a transnasal endoscopic approach using nasal septal flaps pediculated at the sphenopalatine artery. Endoscopic repair is a viable and minimally invasive alternative to traditional craniotomy, however technical difficulties encountered as well as questions that remain unanswered are discussed.
Tumors of the skull base are rare in children and adolescents and present a complicated management problem for oncologists and surgeons alike. Surgical resection is an integral component of the management of many pediatric neoplasms, especially those that are benign or, though not frankly malignant, are locally invasive. The general principles of skull base reconstruction following tumor ablation are applicable to nearly all patients; the reconstructive algorithm, however, is particularly complex in the pediatric population and the potential benefits of therapy must be balanced against the cumulative impact on craniofacial growth and maturity and the donor site morbidity. A retrospective analysis of all patients less than 19 years of age who underwent resection of a skull base tumor was performed. Particular emphasis was placed on the 12 patients who required complex reconstruction by the plastic surgical service. This represents approximately a third of the operated patients. Data were recorded on patient age, tumor pathology and location, prior therapies, surgical approach, extent of resection, margin status, defect components, details of reconstructive methods employed, complications, additional procedures or interventions, and the use and timing of adjuvant therapies. Patient outcome at most recent follow-up was recorded. All patients were followed clinically and by MRI and/or CT scan of the skull base. The reconstructive details recorded included flap choice, recipient vessels, and any concomitant procedures performed. The indications for and details of any staged surgical revisions or prosthetics were also noted. Complications recorded included partial or total flap loss, cerebrospinal fluid leakage, meningitis, infection, abscess, hematoma or seroma formation, delayed healing, and donor site dysfunction. The vertical rectus abdominis myocutaneous free flap was the most common means of reconstruction utilized in this series. Three of 12 patients had reconstruction related complications. Delayed reconstructive procedures or prosthetic interventions have been performed in 6 of the 12 patients who underwent complex reconstructions. On the basis of our experience and previous reports in the literature, we offer the following guidelines for the successful multidisciplinary care of children and adolescents undergoing skull base reconstruction after tumor resection: (1) skull base reconstruction may be safely performed in children and adolescents using free tissue transfer or local flaps; (2) larger defects and those involving more than one anatomic region of the skull base should be repaired with soft-tissue free flaps; and (3) because of the versatility and reliability of free flaps, pedicled flaps should be reserved for limited defects. Because of the potentially synergistic effects of multimodality treatment for skull base malignancies on craniofacial growth and development, we advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity.
Basal encephaloceles are rare entities that can present as congenital diseases; however, traumatic lesions due to head injuries or iatrogenic causes have been described in the literature. In this study the authors aimed to define placement techniques for free grafts in repairing traumatic basal encephaloceles and to describe the long-term effectiveness of endoscopic treatment.
Between September 1997 and December 2006, 8 patients with traumatic encephaloceles underwent endoscopic surgery. A free graft following an underlay (2 cribriform plate and 4 ethmoid fovea defects) or obliteration (2 sphenoid defects) procedure was used as the repair material.
All traumatic basal encephaloceles with the associated skull base defects and cerebrospinal fluid (CSF) leakage were successfully treated via the endoscopic approach. There were no major complications or recurrence of meningitis or leakage of CSF encountered after an average follow-up of 77 months.
Long-term follow-up results demonstrated that endoscopic surgery was suitable for the treatment of traumatic basal encephaloceles. The underlay procedure is more appropriate than the overlay procedure in repairing large defects of the anterior skull base. Meticulous manipulations of the endoscope following precise autograft placement are mandatory for the successful repair of traumatic basal encephaloceles.
Taktika plasticheskogo zakrytiia bazalnykh defektov posle udaleniia sredinnykh novoobrazovanii perednikh otdelov osnovaniia cherepa [Tactics of plastic closure of basal defects after removal of median neoplasms of the anterior sections of the skull base
- D A Golbin
- S N Mindlin
Schneider Pedicled nasoseptal flap reconstruction for craniopharyngiomas in pediatric patients Child's Nervous System
- A Laibangyang
- . D Sh
- Rodgers
- . L Sh
- T Baron
- M Schaeffer
- M A Shikowitz
- S J Mittler
Endoskopicheskaia endonazalnaia diagnostika i lechenie meningoentsefalotsele osnovaniia cherepa [Endoscopic endonasal diagnosis and treatment of skull base meningoencephalocele
- D N Kapitanov
- E V Shelesko
- A A Potapov
- A D Kravchuk
- D N Zinkevich
- M V Nersesian
- L A Satanin
- A V Sakharov
- G V Danilov
Kriterii vybora sposoba plastiki defektov osnovaniia cherepa u bolnykh nazalnoi likvoreei [Criteria for choosing the method of plasty of skull base defects in patients with nasal liquorrhea
- S S Gaidukov
- A N Naumenko