Nasoseptal flap closure of traumatic cerebrospinal fluid leaks

Abstract

The vascularized nasoseptal flap has become a principal reconstructive technique for the closure of endonasal skull base surgery defects. Despite its potential utility, there has been no report describing the use of the modern nasoseptal flap to repair traumatic cerebrospinal fluid (CSF) leaks and documenting the outcomes of this application. Specific concerns in skull base trauma include septal trauma with disruption of the flap pedicle, multiple leak sites, and issues surrounding persistent leaks after traumatic craniotomy. We performed a retrospective case series review of 14 patients who underwent nasoseptal flap closure of traumatic CSF leaks in a tertiary academic hospital. Main outcome measures include analysis of clinical outcome data. Defect etiology was motor vehicle collision in eight patients (57%), prior sinus surgery in four (29%), and assault in two (14%). At the time of nasoseptal flap repair, four patients had failed prior avascular grafts and two had previously undergone craniotomies for repair. Follow-up data were available for all patients (mean, 10 months). The overall success rate was 100% (no leaks), with 100% defect coverage. The nasoseptal flap is a versatile and reliable local reconstructive technique for ventral base traumatic defects, with a 100% CSF leak repair rate in this series.

Keywords: Cranial base; cerebrospinal fluid leak; endoscopy; nasoseptal flap; reconstructive techniques.

Figure 1

Clinical case of a 15-year-old female patient involved in a motor vehicle accident. Prior to arriving at our center, the patient underwent facial reconstruction and two craniotomies. (A) 3-D reconstruction shows the extent of these repairs. (B) Despite these repair attempts, the patient developed persistent high-flow cerebrospinal fluid (CSF) leaks in the sphenoid and posterior ethmoids. The nasoseptal flap provided 100% coverage of all leaks, with no further leaking at 18 months postoperatively. In this figure, arrows indicate persistent CSF leaks and the asterisk, a leak repaired via craniotomy.

Figure 2

Skull base and nasoseptal flap dimensions. (A) Illustration depicting the three modules of the ventral skull base. (B) Data obtained from radioanatomic analyses comparing the relative lengths and widths of the skull base modules and the nasoseptal flap show that the flap has ample size and width to cover any single module of the cranial base. (Series presented in Shah RN, Surowitz JB, Patel MR, et al. Endoscopic pedicled nasoseptal flap reconstruction for pediatric skull base defects. Laryngoscope 2009;119:1067–1075.)