Free middle turbinate mucosal graft reconstruction after primary endoscopic endonasal pituitary surgery

Abstract

The objective is to assess whether free middle turbinate (FMT) graft reconstruction, after endoscopic endonasal pituitary surgery, combines an acceptably low post-operative cerebrospinal fluid (CSF) leak rate with acceptable rhinological morbidity. This study identified 50 patients who underwent endoscopic endonasal pituitary surgery by the senior author in our teaching hospital between May 2011 and June 2012. FMT graft reconstruction was used in 32 cases. 18 patients were judged pre-operatively as not suitable for FMT reconstruction according to a novel skull base reconstructive algorithm. Outcomes examined were: length of inpatient stay; post-operative CSF leak rate; volume of gross tumour resection; and rhinological morbidity. The rhinological morbidity was measured by the completion of the 22 item sinonasal outcome test (SNOT-22) questionnaire by all 32 patients at 6 weeks and 6 months post-surgery. 32 patients were included in the study. 9 patients had functioning microadenomas and 23 macroadenomas. The median inpatient stay was 2 days. There were no post-operative CSF leaks. The rate of gross tumour resection, confirmed on post-operative MRI, was 87.5 %. The mean SNOT-22 score was 31.9 at 6 weeks and 23.4 at 6 months post-operation-a statistically significant drop. The use of the FMT graft in the reconstruction of the sella defect after endonasal endoscopic pituitary surgery provides a robust dural repair with an acceptable rhinological morbidity profile. FMT grafting as part of a defined skull base reconstructive algorithm results in a CSF leak rate of zero and allows early patient discharge without the need for nasal packing or lumbar drains.

ICAR: endoscopic skull‐base surgery

“…In recent years, there have been several studies to examine the role of free‐graft reconstruction particularly in sellar defects after endoscopic endonasal pituitary surgery as a de‐escalated alternative to vascularized pedicled flaps . In a retrospective review of 73 sellar defects reconstructed with layered avascular free grafts, Roxbury et al .…”

“…Of the 50 cases, 12 were excluded in which a macroadenoma >3 cm was present and a high‐flow intraoperative CSF leak was anticipated. The authors concluded that a free middle‐turbinate mucosal graft is a good alternative for sellar defect reconstruction after pituitary surgery for microadenomas and macroadenomas <3 cm with no or low‐flow intraoperative CSF leak …”

Pedicled frontal periosteal rescue flap via eyebrow incision for skull base reconstruction (SevEN-002)

“…Forbes et al [11] reported postoperative CSF leakage in 10% (1/10) of the cases after the endonasal endoscopic transsphenoidal resection of intrinsic third ventricular craniopharyngioma. Several surgical techniques and materials have been utilized to reconstruct the skull base and prevent CSF leakage in clinical settings [10,12,13,20]. Among them, the most widely used material is the nasoseptal flap.…”

Improvement in the Quality of Early Postoperative Course After Endoscopic Transsphenoidal Pituitary Surgery: Description of Surgical Technique and Outcome

“…At the end of the surgery, the right middle turbinate is reset, and the nasal mucosa remains intact. We never remove the middle or upper turbinate because the probability of empty rhinoplasty after surgery is greatly increased, and the chance of postoperative nasal bleeding is increased (13)(14)(15). Second, during the reconstruction of the sellar floor, we routinely take a nasal septal bone fragment for bone reconstruction together with the multilayer repair technology.…”