Minimizing Septectomy for Endoscopic Transsphenoidal Approaches to the Sellar and Suprasellar Regions: A Cadaveric Morphometric Study.

The purpose of this study was to evaluate the effect of posterior septectomy size on surgical exposure and surgical freedom during the endoscopic transsphenoidal approach to the sella and parasellar region. Dissections were performed on 10 embalmed cadaver heads. Dissections started with wide bilateral sphenoidotomies, lateralization of middle turbinates, and a 5-mm posterior septectomy. The posterior septectomy was increased in 5-mm increments to a maximum of 35 mm, followed by bilateral middle turbinectomies. Surgical exposure was defined as the distance between the ipsilateral and contralateral limit of exposure as allowed by the posterior septum along a midsphenoid horizontal meridian. Surgical freedom was defined as the angle between the ipsilateral and contralateral limit. The mean baseline width of the posterior sphenoid sinus was 29.4 ± 3.7 mm. With a 5-mm septectomy, the mean width of surgical exposure was 21.1 ± 2.8 mm. The surgical exposure increased significantly with progressively larger posterior septectomy until a 20-mm posterior septectomy, after which no further increase in surgical exposure or freedom was obtained. Bilateral lateral opticocarotid recesses were accessible with a 15-mm posterior septectomy. The addition of bilateral middle turbinectomies did not significantly increase lateral exposure within the sphenoid sinus compared with middle turbinate lateralization.

The extended nasoseptal flap for coverage of large cranial base defects.

BACKGROUND: The nasoseptal flap (NSF) is commonly used to repair skull base defects via a transnasal endoscopic approach. The original description of the technique includes 2 parallel incisions that follow the sagittal plane of the septum. We describe a novel modification to the traditional NSF that allows coverage along the posterior wall of the frontal sinus. METHODS: In addition to the 2 sagittal incisions, a third incision is made between these coursing along the maxillary crest from the posterior edge to the midportion of the flap. This provides an extension that can be rotated further anteriorly. We report 4 adult patients with skull base defects too large and anterior to cover with a traditional NSF, on whom we successfully reconstructed with the extended flap. We also performed the technique on six cadaver heads (11 flaps) to provide average measurements of the extension. RESULTS: Our patients were successfully repaired with maintained flap survival. We were able to achieve an average of 1.9 cm, or 26.8%, of additional length on the cadaveric study. CONCLUSION: The relaxing incision described here creates a flap that allows for reconstruction of a larger range of skull base defects.

An evaluation of invasive fungal sinusitis outcomes with subsite analysis and use of frozen section analysis.

BACKGROUND: Invasive fungal sinusitis (IFS) is an aggressive mycosis of the nasal cavity with frequent extension to adjacent structures. Occurring more commonly in immunocompromised individuals, prognosis is typically poor despite aggressive treatment. This study aims to examine postoperative outcomes and survival of a cohort of fungal sinusitis patients at an academic center, as well as identify causes of death in IFS patients. METHODS: This study was a retrospective chart review of patient charts and departmental records, yielding patient demographics, medical and surgical treatments, pathology records, and outcomes data. RESULTS: Twenty-seven patients were identified from departmental records between 1998 and 2014. Twenty-one patients presented with Mucor infections, whereas the remaining 6 patients had Aspergillus. All patients were immunocompromised: diabetes (n = 14) and hematologic malignancy (n = 13). Three patients had multiple causes of immunosuppression. Most commonly involved subsites were the maxillary, ethmoid, and sphenoid sinuses. Nasal septum involvement was independently associated with mortality (p < 0.01). Overall mortality was 57.7% within 1 year, although 66.7% of fatalities occurred within 1 month of diagnosis. CONCLUSION: Overall survival for IFS remains poor. Widespread disease and nasal septum involvement were associated with a negative clinical course. Early identification and aggressive surgical and antifungal therapy is warranted. Even despite intense therapy, comorbid conditions and drug toxicity increase mortality and complicate the clinical course.

Perforation of a nasoseptal flap does not increase the rate of postoperative cerebrospinal fluid leak.

BACKGROUND: The nasoseptal flap (NSF) has been shown to be a valuable addition to the reconstructive armamentarium of the endoscopic skull-base surgeon. We aimed to evaluate the rate of postoperative cerebrospinal fluid (CSF) leak after use of a NSF that had a small tear during harvest. METHODS: After Institutional Review Board (IRB) approval, we analyzed our database of patients undergoing skull-base resection. We included all patients who had a NSF reconstruction, septoplasty, and/or spur on preoperative computed tomography (CT) imaging. We then evaluated video of each procedure to determine if a tear occurred in the NSF during harvest. Patient records were reviewed to determine if a postoperative CSF leak occurred. RESULTS: We evaluated video of 21 patients who underwent a skull-base resection, were reconstructed with a NSF, and had either a septoplasty or evidence of a septal spur on CT imaging. Of these 21 cases, 11 small tears occurred during harvest of the NSF flap and none of the patients with a torn NSF had a postoperative CSF leak. CONCLUSION: Our series shows a 0% postoperative CSF leak rate in patients undergoing skull-base reconstruction with a NSF that was torn during harvest. Small tears in the NSF do not seem to affect postoperative CSF leak rates.