Endoscopic Endonasal Reconstruction Using a Pedicled Middle Turbinate Flap for Spontaneous Cerebrospinal Fluid Rhinorrhea

Abstract

However, the postoperative reconstruction for such large defect including TMJ component is a very difficult challenge.For TMJ reconstruction, 2 main options are available: alloplastic condylar prosthesis and autologous tissue transfer. Alloplastic TMJ prosthesis is considered the clinical standard. 5 However, this alloplastic joint replacement is widely used, although only by few surgeons who perform TMJ reconstruction. 6 To prevent prosthesis penetrate the cranial fossa, a combined use of stock prosthesis is necessary. However, this TMJ-stock prosthesis needs elaborate adaptation, which is difficult to achieve after cancer radical surgery. For large, challenging defects, the commercial TMJ prosthesis cannot restore mandible continuity. In comparison with our method, the commercial TMJ prosthesis is very expensive.The autologous bone graft is another option for TMJ reconstruction, such as ribs and the free fibular flap. Costochondral rib graft is the gold standard in children due to growth potential from the cartilage, although it is unpredictable. Moreover, joint ankylosis and a decrease in joint function are complications. Besides, costochondral graft is not resistant to postoperative radiotherapy after advanced oral cancer operation. Vascularized bone graft, such as fibular flap, is another option with acceptable long-term outcomes. 7 However, there are concern such as donor site morbidity and insufficient soft tissue volume to restore large defect like hemimandibulectomy. Furthermore, hypomobility, difficulty in achieving appropriate condylar position, and postoperative ankylosis also reported. 8 For our case, using fibular flap will need another ALT free flap to restore such a large soft tissue defect. It is a timeconsuming operation. Moreover, the possibility of postoperative ankylosis, joint hypomobility, osteonecrosis due to following radiotherapy is another concern. Therefore, we did not perform free fibular flap simultaneously.When alloplastic TMJ condyle is unavailable, a reconstruction plate is a candidate for temporal TMJ reconstruction. Shukla et al 9 first mentioned the use of a reconstruction plate to reconstruct the defect after hemimandibulectomy in cT2N1M0, stage III retromolar trigone squamous cell carcinoma. However, Shukla did not show a clinical picture of his case. Hocaoglu et al 10 presented a case of ameloblastoma treated with segmental mandibulectomy and reconstruction by using a reconstruction plate-bended artificial condyle. His method is similar to ours, but he connected the condylar head and reconstruction plate with wire and screws. However, the author did not mention how he fixed the condylar head to the fossa. Back to our case, we present a well document case with details using this method for the defect of hemimandibulectomy. Such large defect is unable to restore by alloplastic TMJ prosthesis. Free fibular flap is most widely used for such cases. However, postoperative CCRT usually leads to poor healing of the bone, even osteoradionecrosis of the fibular. In such circumstance, ...

“In situ bone flap” combined with vascular pedicled mucous flap to reconstruction of skull base defect

“…(1) Making "pedicled nasal septum mucosal flap: Making nasal septum mucosal flap with vascular pedicle and placing it in the posterior nasal passage for use[ 16 , 20 ]; and (2) Fabrication of in situ bone flap of sellar floor: After grinding the anterior wall of sphenoid sinus, the posterior sphenoid platform, tuberculum sellae, sellar floor, bilateral optic neural tube, internal carotid artery eminence and other structures were exposed. The margin of the open bone window was designed according to the surgical plan.…”

Spontaneous rhinorrhea and idiopathic intracranial hypertension: a complex and challenging association

“…Endoscopic repair is a commonly advocated therapeutic approach considering the risks associated with persistent spontaneous CSF leak [19,20,32,33]. Various repair techniques involving different types of grafts and flaps have been employed to address the leak; however, recurrence rates remain a concern [1,4,6,11,12,14,15,32].…”