Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: Free middle turbinate mucosal grafts

Abstract

Introduction The nasoseptal flap provides hearty, vascularized tissue for reconstruction of Expanded Endonasal Approaches (EEA); however, it produces donor site morbidity due to exposed cartilage. Mucosalization of the septum requires 12 weeks, multiple debridements, and frequent saline rinses. This study addresses the reduction of nasal morbidity by grafting middle turbinate mucosa onto the exposed septum. Methods 15 patients undergoing EEA of the ventral skull base were prospectively enrolled. In seven cases, the sacrificed middle turbinate mucosa was harvested and placed as a free mucosal graft on the septal cartilage. In eight controls middle turbinate grafting was not performed due to tumor involvement. Septal mucosalization and crusting of all patients was quantified at follow-up appointments. An additional 46 patients were retrospectively identified who received middle turbinate grating on their exposed septal cartilage and mucosalization rates determined from clinical records. Results Three weeks after initial operation, the mucosalization rate was 70% versus 5% in the graft and non-graft groups, respectively. At post-operative week six, the mucosalization and crusting were 97% and 5% for the graft group versus 60% and 85% for the non-graft group. Mucosalization rates in the retrospective graft series agreed with the prospective series. Conclusions Despite donor site morbidity, the nasoseptal flap is becoming the standard of care for skull base reconstruction due to its reliability in reestablishing a barrier between the subarachnoid space and the sinonasal tract. It is possible to dramatically increase the rate of septal mucosalization and decrease crusting by using a middle turbinate free mucosal graft. Level of Evidence 1b

Free Mucosal Graft Reconstruction of the Septum after Nasoseptal Flap Harvest: A Novel Technique using a Posterior Septal Free Mucosal Graft

“…Kimple et al described the use of a free mucosal graft harvested from a resected middle turbinate to graft the anterior septal cartilage of the NSF donor site. 15 Kasemsiri et al reported the use of a "reverse flap" in which an anteriorly based posterior septal mucosa flap of the septectomy site was rotated 180 degrees to the opposite side to cover the bare anterior septal cartilage.…”

“…8 With the absence of native mucosa with its mucociliary function, the stagnant blood and secretions on the exposed cartilage create a nidus for crusting which may lead to patient discomfort from nasal fullness, pain, poor nasal airflow, propensity for infection, and need for frequent debridements. 15 Several studies have investigated the sinonasal morbidity associated with use of the NSF with conflicting results. Hanson et al found significant endoscopy score differences in postoperative patients after NSF at 90 days after surgery; however, no differences were noted in quality-of-life questionnaire scores.…”

“…15,16 In one technique, a resected middle turbinate is used in ordered to obtain a free mucosal graft which is placed onto the NSF donor site. 15 In these situations, middle turbinectomy was performed for surgical access; however, this is not always necessary for lesions of the sella, planum sphenoidale, and upper third of the clivus. 23,24 Additionally, resection of the middle turbinate may result in additional morbidity, such as altered nasal airflow, reduced nasal air humidification, and epistaxis from the turbinectomy site.…”

“…15,16 In this study, we present a novel method for reconstruction of the anterior septum after NSF harvest. The technique utilizes the posterior nasal septal mucosa on the side contralateral to the NSF, at the site of the posterior septectomy for transnasal, transsphenoidal approaches to the skull base, which would otherwise be discarded.…”

Anterior skull-base surgery

“…Kimple et al [5] KEY POINTS Anterior skull-base surgery has become progressively more sophisticated with advances in surgical technique and visualization technology. One major drawback of this technique is the donor-site morbidity it produces at the septum because of exposed cartilage, which can take up to 12 weeks to heal.…”