Nasoseptal “Rescue” Flap: A Novel Modification of the Nasoseptal Flap Technique for Pituitary Surgery

Rivera-Serrano, Carlos M.; Snyderman, Carl H.; Gardner, Paul A.; Prevedello, Daniel M.; Kassam, Amin; Carrau, Ricardo; Germanwala, Anand V.; Zanation, Adam M.

doi:10.1002/lary.21329

Cited by 52 publications

(84 citation statements)

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“…This is most commonly performed on the right unless exposure secondary to septal deviation or other sinonasal abnormality limits visualization. At this point, a nasoseptal rescue flap is developed as described by Rivera-Serrano et al 11 Briefly, an incision beginning at the sphenoid os is carried across the sphenoid rostrum to the posterior, superior osseous septum where it is swept superiorly and then anteriorly for approximately one-third to one-half of the superior septum along the sagittal plane. Once incised, a submucoperiosteal/submucoperichondrial plane is developed, allowing the mucosa to be freed beyond the level of the sphenoid floor or posterior choanae, thereby protecting and preserving the posterior septal artery during further dissection.…”

Section: Flap Characteristics and Complicationsmentioning

confidence: 99%

Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak

Thorp

Sreenath²,

Ebert³

et al. 2014

FOC

148

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Endoscopic skull base surgery continues to rapidly evolve, requiring comparable advances in reconstructive techniques. While smaller skull base defects with low intraoperative CSF flow have been successfully managed with a variety of avascular and/or noncellular techniques, larger defects with high CSF flow require more robust repairs often in the form of vascularized flaps, which confer excellent success rates in this setting. Despite these successful outcomes, a paucity of data describing specific patient and operative characteristics and their effects on repair exist. Therefore, a retrospective, consecutive chart review was performed on patients who underwent endoscopic skull base reconstruction with a vascularized flap in the setting of intraoperative CSF leaks. In this series, 151 patients with a mean age of 51 years underwent 152 vascularized flap skull base reconstructions for an array of benign and malignant pathologies. These vascularized flaps included 144 nasoseptal flaps, 6 endoscopic-assisted pericranial flaps, 1 facial artery buccinator flap, and 1 inferior turbinate flap that were used throughout all regions of the skull base. Perioperative (< 3 months) and postoperative (> 3 months) flap complications were assessed and revealed 3 perioperative flap defects (2.0%) defined as a visualized defect within the substrate of the flap and a total of 5 perioperative CSF leaks (3.3%). No patient experienced flap death/complete flap loss in the cohort. Assessed postoperative flap complications included 1 case (0.7%) of mucocele formation, 8 cases (5.3%) of prolonged skull base crusting, and 2 cases (1.3%) of donor-site complication, specifically septal perforation secondary to nasoseptal flap harvest. Among the 152 cases identified, 37 patients received radiation therapy while 114 patients did not undergo radiation therapy as part of the treatment profile. No significant association was found between perioperative complication rates and radiation therapy (p = 0.634). However, a significant association was found between postoperative complication rates and radiation therapy, primarily accounted for by an increased risk for prolonged (> 6 months) skull base crusting (p = 0.025). It is clear that larger skull base defects with high intraoperative CSF flow require thoughtful approach and strong consideration for vascularized repair.

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Section: Flap Characteristics and Complicationsmentioning

confidence: 99%

Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak

Thorp

Sreenath²,

Ebert³

et al. 2014

FOC

148

View full text Add to dashboard Cite

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“…8 There are many literatures in the favour of this technique which ensures superior visualization, magnification, more complete tumor removal and decreased complication rate to that of conventional microscopic technique, thus suggesting it to be a minimally invasive procedure as the nasal and septal architecture is maximally preserved. 6,8,9 The key principle in understanding and successfully achieving good results with these procedure is the close collaboration between the otolaryngologist with good experience in functional endoscopic sinus surgery and the neurosurgeon experienced in transsphenoidal pituitary surgery. 10 The advantage of having a team is the ENT surgeon's familiarity with the route and technique and ability to handle minor complaints of nasal bleed and out patient nasal endoscopy to inspect the post operative wounds.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic Endonasal Transsphenoidal Approach to Pituitary Adenoma: A Multi-disciplinary Approach

Regmi

Thapa

et al. 2017

J Nepal Health Res Council

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Background:The excellent visualization and minimally invasive approach employed in endoscopic endonasal procedures has now revolutionized the pituitary surgery, replacing the transnasal microscopic technique worldwide. However, it involves major shift in hand-eye co-ordination from static 3 dimensional images of microscope to 2 dimensional endoscopic images hence demands training and inter-disciplinary approach. Here we present our experiences in learning and developing a safe endonasal transsphenoidal endoscopic approach to resect pituitary adenomas.Methods: This prospective study was jointly conducted in the departments of ENT and Neurologicals surgery Kathmandu Medical College, Nepal, from September 2014 to August 2016. The endoscopic approach to the sphenoid sinus was performed by an Otolaryngologist and ablative surgery by Neurosurgeon. The ease of procedure, intra operative challenges, surgical cure, post-operative cerebro spinal fluid (CSF) leaks and postoperative complaints were analyzed.Results: Sixteen consecutive patients with pituitary adenoma (macro adenoma=13, micro adenoma =3) were analyzed. There were three intraoperative CSF leak, managed successfully. Two patients developed transient diabetes insipidus and surgical cure rate was 90%. No case had to be switched over to traditional microscopic route due to technical failure. There was no mortality. Conclusions:The endoscopic endonasal transsphenoidal approach to pituitary tumors is a safe and minimally invasive procedure, which can be employed safely in any of our centers in Nepal, equipped with endoscopic sinus surgery and endoscopically trained ENT and Neurosurgeons. A multi disciplinary approach provides good access, greater tumor excision and excellent postoperative follow up.

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“…Authors have suggested modifications to the technique, 1,17 and the data presented in this study provide evidence that preservation of the olfactory strip as a discrete area can avoid significant impact on both olfaction and sinonasal function. Although the concept of an olfactory strip was promoted by colleagues (e.g., Ric Carrau) for many years and alluded to in publications, 21 the focus was usually on septal mucosal recovery. Since then, the observation that mucosal regeneration occurs much more quickly under silastic sheeting 22 with or without free mucosa grafts 23 has shifted the focus away from debate over donor site morbidity.…”

Section: Discussionmentioning

confidence: 99%

The Olfactory Strip and Its Preservation in Endoscopic Pituitary Surgery Maintains Smell and Sinonasal Function

et al. 2015

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).Differing outcomes on olfaction have been reported from transsphenoidal approaches. [1][2][3][4] In general, patients prefer the endoscopic approach, 5 and olfactory scores are better after the endoscopic route. 6 The nasoseptal flap, in particular, to reconstruct the skull base as part of the overall process has been implicated in smell dysfunction. However, much of the literature on the impact of the nasoseptal flap comes from extended skull base surgery. In our institution, utilizing a small modified nasoseptal flap during simple pituitary surgery has greatly improved our reconstructive options and access. However, controversy exists as to the additional morbidity of utilizing such an approach. The existing studies on patients with large skull base tumors are not an appropriate population to discuss the impact of surgery or

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Nasoseptal “Rescue” Flap: A Novel Modification of the Nasoseptal Flap Technique for Pituitary Surgery

Cited by 52 publications

References 0 publications

Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak

Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak

Endoscopic Endonasal Transsphenoidal Approach to Pituitary Adenoma: A Multi-disciplinary Approach

The Olfactory Strip and Its Preservation in Endoscopic Pituitary Surgery Maintains Smell and Sinonasal Function

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