Skull base anatomy and CSF rhinorrhea.
Authors: Lam A, Holbrook E
Abstract
The skull base is an intricate interface between the cranium and face allowing the passageway of vital structures. Anatomic conceptualization forms the platform for surgical approaches and solutions to skull base pathology. Understanding embryogenesis provides further depth into the pathophysiology of congenital defects. This chapter aims to highlight skull base anatomy and embryology along with cerebrospinal fluid physiology and diagnostic evaluation of cerebrospinal fluid leaks.
PMID: 23257547 [PubMed - indexed for MEDLINE] (Source: Advances in Oto-Rhino-Laryngology)
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Pathophysiology of iatrogenic and traumatic skull base injury.
Authors: Gray ST, Wu AW
Abstract
Traumatic skull base injuries can be divided into iatrogenic injuries from surgery and accidental traumatic injuries. The most common cause of iatrogenic skull base injury is endoscopic sinus surgery. The reported rate of cerebrospinal fluid (CSF) leak as a complication of endoscopic sinus surgery is less than 1%. Intraoperative injury most commonly occurs at the ethmoid roof and the lateral lamella of the cribiform plate. Case complexity, such as revision surgery, as well as surgical experience has been shown to be a contributing factor to iatrogenic CSF leaks during endos...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Grafting materials in skull base reconstruction.
Authors: Prickett KK, Wise SK
Abstract
Successful endoscopic repair of the skull base may be performed with a variety of grafting materials. Graft materials discussed in this chapter are broadly categorized as autologous tissue, acellular human dermis, engineered collagen products, rigid support materials and tissue glues. Autologous tissues continue to be widely used due to their safety, availability, and low cost. Engineered collagen products and acellular dermis are favored in revision cases and larger repairs. The need for rigid support continues to be an area of controversy as pedicled grafts are incr...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Free graft techniques in skull base reconstruction.
Authors: Ting JY, Metson R
Abstract
Over the last 20-30 years, the management of anterior skull base defects, CSF leaks and encephaloceles has shifted towards endoscopic, minimally invasive approaches. Whether their etiology is spontaneous or traumatic, the large majority of these lesions can be repaired with free mucosal grafts. Such grafts may be readily harvested from the nasal septum or turbinates and applied as either a single layer reconstruction for small leaks or as a multilayer reconstruction for larger defects. The accessibility, ease of placement, and high take rate associated with free mucosal ...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Nasoseptal flap.
Authors: Pinheiro-Neto CD, Snyderman CH
Abstract
The nasoseptal flap had an important role in the development of endoscopic endonasal surgery of the cranial base. The flap is pedicled upon the posterior septal artery, which is a terminal branch of the sphenopalatine artery. The reliable vascular supply promotes rapid healing and the flap is an effective barrier for the prevention of CSF leaks. For large skull base defects, it has dramatically decreased the risk of a postoperative CSF leak to less than 5%. The nasoseptal flap is a versatile flap with a wide arc of rotation that allows the flap to reach defe...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Sphenopalatine-derived pedicled flaps.
Authors: Suh JD, Chiu AG
Abstract
A variety of local flaps based on the sphenopalatine artery are available for endoscopic skull base reconstruction including the nasoseptal flap, middle turbinate flap, and posteriorly based inferior turbinate flap. This section will describe the alternatives to the nasoseptal flap, emphasizing the relevant anatomy, indications and technical aspects involved with their use.
PMID: 23257552 [PubMed - indexed for MEDLINE] (Source: Advances in Oto-Rhino-Laryngology)
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Anteriorly based pedicled flaps for skull base reconstruction.
Authors: Meier JC, Bleier BS
Abstract
The expansion of endoscopic skull base surgery has resulted in the creation of large defects that must be repaired to ensure separation of the cranial vault from the nasal cavity. The workhorse of anterior skull base reconstruction remains the nasoseptal or Hadad-Bassagasteguy flap. Despite its success, the nasoseptal flap is limited in its ability to reach extremely anterior defects including those involving the frontal break, posterior frontal table, and anterior cribiform plate. Alternative approaches utilizing anteriorly pedicled flaps have been described which exp...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Pedicled extranasal flaps in skull base reconstruction.
Authors: Kim GG, Hang AX, Mitchell CA, Zanation AM
Abstract
Cerebrospinal fluid (CSF) leaks most commonly arise during or after skull base surgery, although they occasionally present spontaneously. Recent advances in the repair of CSF leaks have enabled endoscopic endonasal surgery to become the preferred option for management of skull base pathology. Small defects (<1 cm) can be repaired by multilayered free grafts. For large defects (>3 cm), pedicled vascular flaps are the repair method of choice, resulting in much lower rates of postoperative CSF leaks. The pedicled nasoseptal flap (NSF) constitut...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Microvascular free flaps in skull base reconstruction.
Authors: Herr MW, Lin DT
Abstract
The anatomical challenges of skull base surgery are well known. Furthermore, ablative and traumatic defects in this region produce complex reconstructive problems with a high risk of significant postoperative morbidity and mortality. Over the past two decades, microvascular free tissue reconstruction following open resection has been shown to improve outcomes and reduce complication rates when compared to the traditional use of pedicled flaps. The increasing use of free tissue transfer has been further strengthened by improved technical expertise and high flap success rate...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Spontaneous cerebrospinal fluid leak and management of intracranial pressure.
Authors: Soler ZM, Schlosser RJ
Abstract
Cases of cerebrospinal fluid (CSF) rhinorrhea without a clear etiology are known as spontaneous CSF leaks. Spontaneous CSF leaks most commonly occur in the ethmoid skull base or lateral sphenoid and rarely stop without surgical intervention. This chapter reviews the clinical presentation, diagnostic workup, and treatment of patients with spontaneous CSF rhinorrhea. Specific attention will be given to endoscopic methods of repair and the importance of idiopathic intracranial hypertension as a possible comorbidity and contributing factor.
PMID: 23257556 [PubMe...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Endoscopic reconstruction of frontal, cribiform and ethmoid skull base defects.
This article discusses the planning and execution in ESBR for anterior fossa defects. Factors influencing the choice of reconstruction (flap location, size, influence of raised intracranial pressure, high flow CSF leak, radiotherapy) are examined. The reconstructive options are discussed, including the nasoseptal flap (NSF), inferior turbinate pedicled flap and the endopericranial flap, with particular emphasis on the technical aspects of reconstruction using the NSF. A step-by-step description, with an accompanying video, is provided. Techniques applicable to ESBR in general (subdural graft placement, graft/flap placement...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Planum, tubercular, sellar and clival defects.
Authors: Wei CC, Palmer JN
Abstract
Transsphenoidal and extended transsphenoidal approaches have provided improved surgical access to numerous intradural and extradural tumors from the retrosellar area to the craniovertebral junction. The evolution in reconstruction of planum, tubercular and clival skull base defects has progressed from the use of free tissue grafts alone to the use of free tissue grafts in combination with vascularized flaps. Sellar floor reconstruction is usually necessary only if intraoperative CSF leaks, prolapse of the suprasellar cistern, or bleeding from the medial aspect of the cav...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Quality control approach to cerebrospinal fluid leaks.
Authors: Snyderman CH, Gardner PA
Abstract
Cerebrospinal fluid (CSF) leaks are one of the most common complications of endoscopic sinus and skull base surgery, and are associated with significant morbidity and cost. A quality improvement program can be designed for individual surgeons or groups of surgeons to monitor outcomes and implement changes to decrease the risk of a postoperative CSF leak. Analytic tools include a root cause analysis, statistical analysis of risk factors, and predictive modeling. Monitoring of outcomes is accomplished with a time series plot or run chart. A circular action loop for ...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Postoperative care following skull base reconstruction.
Authors: Ramakrishnan VR, Waziri A
Abstract
Postoperative care following skull base surgery and reconstruction is critical for achieving optimal outcomes and patient satisfaction. The choice of reconstructive technique and grafting materials may significantly influence the postoperative planning and monitoring for each patient. The overarching goals of postoperative management include avoidance and early recognition of complications, facilitation of wound healing at the surgical site(s), and quick recovery for the patient. Planning for postoperative care is initiated in the preoperative and intraoperative ...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
Complications of skull base reconstruction.
Authors: Chaaban MR, Woodworth BA
Abstract
The skull base is an anatomically challenging location that is unique in that it requires three-dimensional considerations when formulating a reconstruction plan. Various methods have been described for repair including open, endoscopic and endoscopic-assisted approaches. Each of these can have complications that can arise either directly from access to the lesion or defect, or indirectly arising from patient characteristics, anesthetic considerations, as well as postoperative care. It is of utmost importance for the surgeon to select the appropriate technique and...
Source: Advances in Oto-Rhino-Laryngology - December 2, 2014 Category: ENT & OMF Tags: Adv Otorhinolaryngol Source Type: research
