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. 2014:2014:346873.
doi: 10.1155/2014/346873. Epub 2014 May 7.

Management of anterior skull base defect depending on its size and location

Manuel Bernal-Sprekelsen  1 , Elena Rioja  2 , Joaquim Enseñat  3 , Karla Enriquez  4 , Liza Viscovich  4 , Freddy Enrique Agredo-Lemos  5 , Isam Alobid  4
Affiliations

Management of anterior skull base defect depending on its size and location

Manuel Bernal-Sprekelsen et al. Biomed Res Int. 2014.

Abstract

Introduction: We present our experience in the reconstruction of these leaks depending on their size and location.

Material and methods: Fifty-four patients who underwent advanced skull base surgery (large defects, >20 mm) and 62 patients with CSF leaks of different origin (small, 2-10 mm, and midsize, 11-20 mm, defects) were included in the retrospective study. Large defects were reconstructed with a nasoseptal pedicled flap positioned on fat and fascia lata. In small and midsized leaks. Fascia lata in an underlay position was used for its reconstruction covered with mucoperiosteum of either the middle or the inferior turbinate.

Results: The most frequent etiology for small and midsized defects was spontaneous (48.4%), followed by trauma (24.2%), iatrogenic (5%). The success rate after the first surgical reconstruction was 91% and 98% in large skull base defects and small/midsized, respectively. Rescue surgery achieved 100%.

Conclusions: Endoscopic surgery for any type of skull base defect is the gold standard. The size of the defects does not seem to play a significant role in the success rate. Fascia lata and mucoperiosteum of the turbinate allow a two-layer reconstruction of small and midsized defects. For larger skull base defects, a combination of fat, fascia lata, and nasoseptal pedicled flaps provides a successful reconstruction.

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Figures

Figure 1
Figure 1
Algorithm of the management of CSF leaks. CISS = constructive interference in steady state.
Figure 2
Figure 2
(a) Nasoseptal pedicled flap dissected from the left side. Arrows pointing to remnant of the inferior aspect of the vomer and *dura. (b) Nasoseptal flap (∗) positioned over the skull base. Arrow pointing at the edges of the flap.
Figure 3
Figure 3
Reconstruction of a defect at the left cribriform plate. (a) Fascia lata introduced in an overlay position. Intracranial pressure and pulsations end up pushing the fascia onto the dura. Middle turbinate resected (∗ indicating its original attachment). (b) Free mucosal graft from the middle turbinate.
Figure 4
Figure 4
Same patient as in Figure 2(a) 4 months after reconstruction. Note the missing septum (vomer remnant inferiorly and the choanal border). *Reconstructed area of the nasoseptal flap.
Figure 5
Figure 5
Sagittal view of the reconstructed planum sphenoidale, pituitary, and clivus. Note the enhancement of the perfusion of the pedicled nasoseptal flap (arrows).
See this image and copyright information in PMC

References

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