Long-Term Outcome of Endonasal Endoscopic Skull Base Reconstruction with Nasal Turbinate Graft

Abstract

Objective: To study the long-term outcome of endonasal endoscopic skull base reconstruction with nasal turbinate tissue free graft. Patients and Methods: This study included 55 consecutive patients who underwent endonasal endoscopic skull base reconstruction with nasal turbinate graft and were available for follow-up. They were 30 patients with pituitary adenomas, 20 with cerebrospinal fluid (CSF) rhinorrhea of different etiologies, three with meningoencephalocele, and two with skull base meningiomas. Autologous nasal turbinate tissue materials were used in reconstructing the skull base defect. Clinical follow-up with endoscopic nasal examination was done routinely 1, 3, 6, and 12 months after surgery. Computed tomography and magnetic resonance imaging were performed when indicated. The follow-up period ranged from 6 months to 8 years. Results: There were no major operative or postoperative complications. Nasal turbinate graft was effective in sealing of intraoperative CSF leak, obliteration of dead space, and anatomic reconstruction of the skull base. There was no evidence of graft migration or inflammatory changes. Starting from 3 months after surgery to the rest of the follow-up period, endonasal endoscopic view of the site of duraplasty showed that: with small skull base defect (less than 5 mm), there was neither dural pulsation nor prolapse; with moderate-sized defect (5 to 10 mm), there was dural pulsation without prolapse; with larger defect (> 10 mm), there was dural pulsation and prolapse. These finding were constant regardless of the etiology of the lesion and the reconstruction material used. Conclusions: This long-term study demonstrated the efficacy of nasal turbinate graft in sealing of CSF leak without any delayed complications. Other rigid materials may be considered in reconstruction of large skull base defect (more than 10 mm) to prevent dural prolapse and herniation. For any future endonasal procedure for those patients, who had previous endonasal

Osseous Repair in Minimally Invasive Reconstruction of Anterior Skull Base Defects

“…In subsequent meta-analyses of surgically created defects, 6,7 areas of high-flow (i.e., high CSF pressure) were at risk of failure with free grafts and appeared to benefit from vascularized tissue grafts. El-Banhawy et al 12 determined that the size of the bony defect determined the dural pulsation and prolapse at the site of the duraplasty, implying that a rigid underlay may mitigate pulsations from the intracranial compartment as a graft attempts to adhere to the skull base. It is arguable if bony or rigid repair of the defect is required at all, however.…”

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

“…Previous studies have demonstrated that an inferiorly based middle turbinate mucosal graft can be rotated widely and serve as reconstruction material for surgical defects after sellar, transtuberculum/transplanum, or unilateral transcribiform approaches, as well as treatment of post‐traumatic and spontaneous CSF leaks 16, 23. The use of middle turbinate mucosa as a free graft has also been successfully reported for managing CSF leaks and to reconstruct skull base defects created by minimally invasive pituitary surgery and to repair CSF rhinorrhea, meningoceles, and meningiomas 26–29. The middle turbinate nasal mucosa graft has been shown to be reliable and cost efficient 28.…”

Pneumocephalus with BiPAP use after transsphenoidal surgery

“…Animal models have shown that integration of fascial dural repair may take place as soon as one week postoperatively, with a durable fibrous ingrowth as soon as two weeks [18]. This healing process, however, depends greatly on the size of the skull base defect, the nature of the material used for repair, and history of radiation treatment [19]. …”