Outcomes of transnasal endoscopic repair of cerebrospinal fluid leaks: a prospective cohort study

Abstract Background Although cerebrospinal fluid (CSF) leak repair of the anterior and middle skull base defect by endonasal endoscopic surgery (EES) presents one of the more difficult challenges, it has shown high success rates with less morbidity. Our objective is to evaluate the outcomes of transnasal endoscopic repair of CSF leak regarding success rate, impact on olfaction, and sinonasal function. Methods A prospective cohort study was conducted to evaluate the CSF leak repair outcomes related to the site, size of the defect, surgical techniques, and the materials that been used through Smell Identification Test (SIT), 22-item Sino-Nasal Outcome Test (SNOT-22), Perioperative Sinus Endoscopy score (POSE), and Lund-MacKay Scoring (LM) of CT scan. Results Twenty-one patients were enrolled in the study; 12 out of 21 were females with a higher prevalence of traumatic causes of 61.9%. Different techniques and materials were used for the repair with a success rate recorded at 90.5% after the first closure attempt. The mean standard deviation (SD) scores postoperatively (after 6 months) was markedly decreased in SNOT 22 with mean (SD) 5.55 ± 3.6, slightly increase in POSE (mean ± SD = 0.43 ± 0.6), and slightly decrease in SIT (mean ± SD =10.31 ± 4.7) and LM (mean ± SD = 0.57 ± 0.7). Conclusion Transnasal endoscopic CSF leak repair is an effective technique for skull base defect closure with a high success rate and no valuable morbidity to sinonasal function other than mild hyposmia in patients where nasoseptal (NSF) and septal flap have been used. Trial registration The study was approved by the institutional review board and ethics committee of (The Arab Board of Health Specializations) with order no. (453) on 1April 2018

How to preserve the olfaction in harvesting the nasoseptal flap in endoscopic skull base surgery

The introduction of nasoseptal flap for the skull base defects reconstruction in endoscopic endonasal approaches represents a revolution that dramatically reduced incidence of the cerebrospinal fluid leaks, however it may be associated with comorbidities like olfactory hypofunction. Objectives: We revise our anatomical knowledge and surgical experience in order to describe an easy and safe technique to avoid olfaction hypofunction. Methods (Surgical technique): A simple anatomical surgical landmark proposed for identification of the olfactory area on the septum, based on the anatomy of the lateral nasal wall. More specifically, the level of the common axilla of the turbinates can be utilized to identify the distribution of the olfactory fibers on the nasal septum. Results: There was no significant change in the subjective olfaction identification score in the postoperative period. Conclusion: The common axilla line considered as a crucial landmark and an easy way to spare olfaction during harvesting the nasoseptal flap

Use of the pedicled nasoseptal flap in the endoscopic management of cholesterol granulomas of the petrous apex

Background: Nowadays the endoscopic approach represents a useful alternative to traditional surgical approaches in the treatment of cholesterol granulomas (CGs) of the petrous apex (PA). Recently the nasoseptal flap (NSF) has been employed to permit long-term patency of drainage site. The purpose of this study is to report our experience with the NSF in the endoscopic management of CG and to analyze the advantages, limitations, and outcomes of the technique. Methods: A retrospective analysis was carried out on 10 patients affected by CG of the PA who had been treated endoscopically, using the NSF. Results: An endoscopic transpterygoid approach was used for 6 patients and the remaining 4 were treated using the transclival approach. A NSF was used in all 10 cases. In 6 cases the flap was ipsilateral to the lesion whereas in 4 it was contralateral. In 90% of our patients no evidence of disease was observed after a mean follow-up period of 35.7 months, with resolution of their symptoms. One patient presented a recurrence because of a technical error (inadequate placement of the flap in the cavity), and has been retreated endoscopically. Conclusion: The pedicled NSF seems to be helpful in avoiding the concentric growth of the granulomatous cyst epithelium while assuring ventilation and drainage of the cyst. However, bigger studies with longer-term follow-up are needed to confirm these findings. Correct and meticulous placement of the flap inside the cystic cavity is the most critical issue for the success of the procedure