Long‐term sinonasal outcomes after endoscopic skull base surgery with nasoseptal flap reconstruction

Abstract

Objectives The utilization of the nasoseptal flap (NSF) in endoscopic anterior skull base surgery (EASB) has resulted in reduced rates of postoperative cerebrospinal fluid leak (CSF). The long‐term impact on sinonasal function after surgery remains incompletely defined. Methods A consecutive series of patients undergoing EASB with NSF and with at least 3 years follow‐up was prospectively evaluated. Patient demographics, pre‐ and postoperative Sino‐nasal Outcome Test‐22 (SNOT‐22) scores, Lund‐Mackay scores (LMS), CSF leak, and sinonasal complications were analyzed. Results A total of 46 patients undergoing EASB with NSF met inclusion criteria. The mean follow‐up was 67.4 months (range 39–90, standard deviation [SD] 14.2 months). No statistically significant differences were noted between the mean overall pre‐ (16) and postoperative SNOT‐22 scores (18). SNOT‐22 scores improved in 27 patients (58.7%), deteriorated in 17 patients (37.0%) and stayed the same in two patients (4.3%). Deterioration in SNOT‐22 scores was greater in younger (mean change + 7.2 [SD17.4] vs. older patients −3.4 [SD 7.5], P = 0.010). A statistically significant increase in LMS was noted (mean preoperative LMS0.9 vs. mean postoperative LMS 2.2, P = 0.001). The LMS decreased in nine patients (19.6%), increased in 22 patients (47.8%), and remained the same in 15 patients (32.6%). One patient (2.2%) developed a postoperative CSF leak following resection of metastatic skull base lesion and was successfully treated with placement of a lumbar drain, Foley catheter balloon, and strict bed rest. One patient (2.2%) developed a postoperative mucocele requiring decompression 3 years after initial surgery. Conclusion Whereas long‐term sinonasal quality of life is overall improved in the majority of patients following NSF use for EASB, younger patients show higher incidence of deterioration. Increased sinus opacification on imaging is generally noted and may require continued follow‐up and management. The incidence of reoperation for symptomatic mucocele formation is low. Level of Evidence 4 Laryngoscope, 129:1035–1040, 2019

Spontaneous Nasal Cerebrospinal Fluid Leak Repaired With Single-Layer Mucoperichondrial Graft: Long-term Results

“…9 Accordingly, Riley et al published a prospective study questioning the long-term impact of the nasoseptal flap on the sinonasal function. 13 In fact, both the postoperative 22-item Sino-nasal Outcome Test-22 (SNOT-22) questionnaire 14 and the radiologic Lund-Mackay score (LMS) 15 showed a significant worsening, indicating a deterioration in function following anterior skull base surgery with nasoseptal flap. 13 Several authors more recently proposed other pedicled flap to repair ASBs even though long-term follow-up studies have not been published at present.…”

“…13 In fact, both the postoperative 22-item Sino-nasal Outcome Test-22 (SNOT-22) questionnaire 14 and the radiologic Lund-Mackay score (LMS) 15 showed a significant worsening, indicating a deterioration in function following anterior skull base surgery with nasoseptal flap. 13 Several authors more recently proposed other pedicled flap to repair ASBs even though long-term follow-up studies have not been published at present. [16][17][18][19] The majority of the authors agree with the use of composite osteomucosal or chondromucosal grafts for defects bigger than 3 to 4 cm.…”

Vascular pedicled flaps for skull base defect reconstruction

“…1,17,6 NSF success rates range from 70% to 100% in single institution studies, with most reporting success rates of 90% or higher. 1,21,22,[38][39][40] Other NSF variants Successful use of bilateral NSFs, termed the "Janus flap," has been reported for defects that may not be adequately repaired by a single NSF. 43,45 Single NSFs can also be enlarged by moving the inferior incision laterally to include mucosa from the inferior turbinate or even the entire lateral wall.…”

“…The absence of postoperative CSF leaks is generally considered to be the primary measure of success for reconstruction of skull base defects 1,17,6 . NSF success rates range from 70% to 100% in single institution studies, with most reporting success rates of 90% or higher 1,21,22,38‐40 . Additional NSF complications and their prevalence were assessed in a 2018 systematic review by Lavinge et al: flap necrosis (4 studies; [0%‐1.3%]), mucocele formation (5 studies; [0%‐3.6%]), septal perforation (6 studies; [0%‐14.4%]), and nasal dorsum collapse (2 studies, [0.7%‐5.8%]).…”

Utility of the Nasoseptal “Rescue” Flap Approach: Analysis of 125 Consecutive Patients and Implications for Routine Transsphenoidal Surgery

“…6,7 In a prospective study examining patients undergoing ESBS with NSF reconstruction, there was a significant increase in the 22-item Sino-Nasal Outcome Test nasal symptom subdomain as well as Lund–Mackay scores postoperatively. 8 Recent studies have shown that skull base defects that are small in size with a low-flow CSF leak can be reconstructed with a wide variety of multilayered (or even monolayered) avascular free grafts or biosynthetic materials with high success rates and limited morbidity. 3,9 In the setting of routine transspehnoidal surgery, where the risk of a high-flow CSF leak is low, the upfront harvest of the NSF per routine, could lead to an unnecessary flap with its attendant morbidity.…”