Perioperative management in endoscopic endonasal skull‐base surgery: a survey of the North American Skull Base Society

Background For patients with obstructive sleep apnea (OSA), there is a lack of knowledge regarding the impact of continuous positive airway pressure (CPAP) on the nasal cavity. There is a significant need for evidence-based recommendations regarding the appropriate use of CPAP following endoscopic sinus and skull base surgery. Objective The goal of this study is to translate a previously developed cadaveric model for evaluating CPAP pressures in the sinonasal cavity by showing safety in vivo and quantifying the effect of positive pressurized air flow on the nasal cavity of healthy individuals where physiologic effects are at play. Methods A previously validated cadaveric model using intracranial sensor catheters has proved to be a reliable technique for measuring sinonasal pressures. These sensors were placed in the nasal cavity of 18 healthy individuals. Pressure within the nose was recorded at increasing levels of CPAP. Results Overall, nasal cavity pressure was on average 85% of delivered CPAP. The amount of pressure delivered to the nasal cavity increased as the CPAP increased. The percentage of CPAP delivered was 77% for 5 cmH2O and increased to 89% at 20 cmH2O. There was a significant difference in mean intranasal pressures between all the levels of CPAP except 5 cmH2O and 8 cmH2O ( P < .001). Conclusion On average, only 85% of the pressure delivered by CPAP is transmitted to the nasal cavity. Higher CPAP pressures delivered a greater percentage of pressurized air to the nasal cavity floor. Our results are comparable to the cadaver model, which demonstrated similar pressure delivery even in the absence of anatomic factors such as lung compliance, nasal secretions, and edema. This study demonstrates the safety of using sensors in the human nasal cavity. This technology can also be utilized to evaluate the resiliency of various repair techniques for endoscopic skull base surgery with CPAP administration.

Section: Introductionmentioning

confidence: 99%

Qualitative Assessment of the Effect of Continuous Positive Airway Pressure on the Nasal Cavity

Reilly

Huntley

Boon

et al. 2020

“…[18][19][20][21][22] The trend that many are "over working the workhorse," and overusing the NSF was further highlighted in a recent survey of the NASBS in which 50% of surgeons reported used the NSF for low-flow intraoperative CSF leaks in routine transsphenoidal surgery, and another 15% even used it when no leak was encountered. 23 We suspect that this may be related to the technique of routinely harvesting the NSF upfront, which then leads to the conundrum of what to do with a raised NSF at the end of a procedure in cases where an NSF may not actually be needed.…”

Section: Discussionmentioning

confidence: 99%

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

Cappello

Tang

Roxbury

et al. 2019

Self Cite

Introduction The nasoseptal flap (NSF) is the reconstructive workhorse for endoscopic skull base surgery (ESBS). However, there is morbidity associated with its use and it is not always required for reconstruction. The bilateral nasoseptal “rescue” flap (NSRF) technique offers a quicker alternative to upfront NSF harvest, yet permits the use of a tailored NSF if needed after the defect has been created. The utility and implications of this strategy have not been well studied. Methods We retrospectively analyzed 125 consecutive transsphenoidal cases where an NSRF approach was used from January 2015 to October 2017 at the Cleveland Clinic. Records were analyzed for conversion to NSF, outcomes, and reconstruction-related complications. Results The mean age of patients included in the study was 51 years, with 51% females. NSRF was converted to full NSF in only 16% of cases. Rationale for conversion included an unanticipated high-flow (7) or low-flow (12) cerebrospinal fluid (CSF) leak and an exposed internal carotid artery (1). NSRF was utilized and converted to formal NSF in 3 patients who had previous remote transsphenoidal surgery. One patient who had an NSRF without a full NSF raised had a postoperative CSF leak; however, no CSF leaks or flap ischemia was noted for those who had full NSFs raised, even in revision surgery. Conclusion NSRF approach provides the reliability and flexibility of vascularized reconstruction, without the perioperative disadvantages of an upfront NSF harvest. The low and successful conversion rate to NSF demonstrates the utility of this strategy which should be incorporated into the standard approach for routine transsphenoidal surgery.

“…7 A recent survey study likewise found highly variable practice patterns among respondents with respect to skull base surgery. 8…”

Section: Discussionmentioning

confidence: 99%

Postoperative Continuous Positive Airway Pressure Use and Nasal Saline Rinses After Endonasal Endoscopic Skull Base Surgery in Patients With Obstructive Sleep Apnea: A Practice Pattern Survey

Choi

Reddy

Weitzel

et al. 2018

Background Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. Methods A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. Results Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients’ CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon’s choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001). Conclusion Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.