Objective?When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design?Cadaveric anatomical study. Participants?Cadaveric specimens. Main Outcome Measures?Flap size, arc of rotation, and reconstructive applications were assessed. Results?The average width of the flap was 5.46???0.58 cm (7.32???0.59 cm with septal mucosa). The average length of the flap was 5.01???0.58 cm (5.28???0.37 cm with septal mucosa). The average surface area of the flap was ? 27.26???3.65 cm2 (40.53???6.45 cm2 with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion?The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable.

The vascularized middle turbinate flap is a reliable reconstructive technique for the reconstruction of moderate-sized skull base defects. It can be considered either as the first choice of closure or as an alternative to the nasoseptal flap when this is not available. Different flap combinations may facilitate skull base defect reconstruction.

T he endoscopic endonasal transpterygoid approach is a lateral extension of the midline endonasal route; although it was initially described to access only the lateral recess of the sphenoid sinus, currently this route is used to reach the most lateral aspect of the skull base. In this surgical scenario, injury to the internal carotid artery (ICA) is one of the most feared complications.The vidian nerve (VN) has been clearly described as a critical landmark for the safe identification of the petrous ICA in the foramen lacerum (FL) during the endoscopic ABBREVIATIONS ET = eustachian tube; FL = foramen lacerum; ICA = internal carotid artery; VC = vidian canal; VELPPHA = vidian nerve, eustachian tube, foramen lacerum, petroclival fissure, and pharyngobasilar fascia; VN = vidian nerve. OBJECTIVEThe endoscopic endonasal transpterygoid route has been widely evaluated in cadavers, and it is currently used during surgery for specific diseases involving the lateral skull base. Identification of the petrous segment of the internal carotid artery (ICA) is a key step during this approach, and the vidian nerve (VN) has been described as a principal landmark for safe endonasal localization of the petrous ICA at the level of the foramen lacerum. However, the relationship of the VN to the ICA at this level is complex as well as variable and has not been described in the pertinent literature. Accordingly, the authors undertook this purely anatomical study to detail and quantify the peri-lacerum anatomy as seen via an endoscopic endonasal transpterygoid pathway. METHODS Eight human anatomical specimens (16 sides) were dissected endonasally under direct endoscopic visualization. Anatomical landmarks of the VN and the posterior end of the vidian canal (VC) during the endoscopic endonasal transpterygoid approach were described, quantitative anatomical data were compiled, and a schematic classification of the most relevant structures encountered was proposed. RESULTS The endoscopic endonasal transpterygoid approach was used to describe the different anatomical structures surrounding the anterior genu of the petrous ICA. Five key anatomical structures were identified and described: the VN, the eustachian tube, the foramen lacerum, the petroclival fissure, and the pharyngobasilar fascia. These structures were specifically quantified and summarized in a schematic acronym-VELPPHA-to describe the area. The VELPPHA area is a dense fibrocartilaginous space around the inferior compartment of the foramen lacerum that can be reached by following the VC posteriorly; this area represents the posterior limits of the transpterygoid approach and, of utmost importance, no neurovascular structures were observed through the VELPPHA area in this study, indicating that it should be a safe zone for surgery in the posterior end of the endoscopic endonasal transpterygoid approach. CONCLUSIONS The VELPPHA area represents the posterior limits of the endoscopic endonasal transpterygoid approach. Early identification of this area can enhance the safety of the e...

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BACKGROUND Intraoperative injury during endoscopic endonasal surgery of the carotid artery has been previously described in the literature. However, the accidental damage of the basilar artery in such scenario is not defined. OBJECTIVE To define the protocol of action for massive bleeding from an artery in the posterior fossa. METHODS The reported patient was diagnosed with a partially calcified clival chordoma featured by a huge intradural component. An endoscopic endonasal transpterygoid transclival approach was selected for the treatment of this tumor. During the surgical procedure, the basilar artery injury was injured, causing intense bleeding. We present and discuss the surgical maneuvers that could save a patient's life after this dramatic complication. RESULTS Different techniques were performed in order to control the massive bleeding, including injection of hemotastic matrix with thrombin (Floseal©), bipolar coagulation, and vessel reconstruction by means of a vascular clip. Finally, an autologous muscle graft reinforced with an overlying fibrin sealant patch (Tachosil©) was chosen and was an effective technique. Afterwards, the patient was treated with a flow diverter device to occlude an iatrogenic pseudoaneurysm. A monoplegia of the right upper limb was the only remarkable sequel 6 mo after surgery. CONCLUSION The muscle graft together with the coordinated action with interventional neuroradiology for the reconstruction of the vessel are possibly the best options to try to preserve the neurological function. In such a scenario, the assumption of potential ischemic events prevails over the intraoperative death of the patient.