Non-pedicled vs vascular pedicled nasal flap in repair of

cerebrospinalfluid rhinorrhea

J. AGUILAR CANTADOR, A. JURADO-RAMOS, J. GUTIÉRREZ JODAS, N. MÜLLER LOCATELLI, E. CANTILLO BAÑOS & F. MUÑOZ DEL CASTILLO

Department of Otolaryngology-Head and Neck Surgery, Reina Sofía University Hospital and Department of Medicine (Dermatology, Medicine and Otolaryngology), School of Medicine, University of Cordoba, Spain

The transnasal endoscopic approach – first choice surgical technique – cerebrospinal fluid (CSF) rhinorrhea of the anterior, sellar, and parasellar regions of the skull base.

In 1952, Hirsch – first transnasal closures of CSF fistulas after hypophysectomies using a nasal flap (NF).

Such repairs – fatty tissue, fascia, muscle, cartilage, lyodura, turbinal mucosa – vascular pedicled nasal flaps – inferior and middle turbinate and the septum.

INTRODUCTION

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Endoscopic approaches – designed, manipulated, and inserted with high efficiency and a low morbidity.

Novel technique – endonasal reconstruction of skull base defects – posterior pedicle nasoseptal flap, the Hadad- Bassagasteguy flap – reliable and versatile – extensive defects of the anterior, middle, clival, and parasellar skull base.

Aim of this study – evaluate the results and comparing the two techniques.

INTRODUCTION

Retrospective study – June 2000 to May 2010.

33 patients.

22 (66.6%) – pedicled Nasal Flap (NF) – inferior or middle turbinate or nasal septum.

11 – non-pedicled Nasal Graft (NG) – lower or middle turbinate.

First 11 patients – non-pedicled NG.Next 22 patients – pedicled NF.

Range – surgery as the first option.

Preoperatively – nasal endoscopy and computed tomography myelography (CTM) – location of the defect.

MATERIAL AND METHODS

Nasal endoscopy – no rhinoliquorrea – ‘chest with head down’ maneuver – electrophoresis of the liquid – β-2 transferrin.

After surgical treatment – re-assessed monthly during the first year – every 6 months.

Variables analyzed – age, sex, etiology of the fistula, location, size of the defect, time tracking, surgical technique used, success of the technique, and complications.

Informed consent.

MATERIAL AND METHODS

SURGICAL TECHNIQUE

Endoscopic endonasal surgery GA – 0°, 30°, and 45° rigid endoscopes.

Decongestant – topical tetracaine and adrenaline 1:10 000.

Inferior and middle turbinate and septum infiltrated with 0.5% lidocaine and epinephrine 1:100 000.

Preparing the recipient site – removing the mucosa with suction shaver blade – perfect adhesion of the graft to the bone (overlay technique). Extensive ethmoidectomy, sphenoidotomy or Draf III – location of the fistula – ethmoidal roof, sphenoids or frontal sinus, respectively.

MATERIAL AND METHODS

Measured the size of the defects with a pituitary rongeur.

Highflow leaks – opening of the third ventricle.

Pedicled nasal flap (NF) – elevated a mucoperiosteal flap – lower or middle turbinate, pedicled by the turbinal arteries – placed flesh-side down on the fistular area.

Distant fistula – nasoseptal flap – mucoperichondric flap – septum – nasoseptal artery – anterior, sellar, and parasellar regions of the skull base.

Free nasal graft (NG) – broad free flap of mucoperiosteum – middle or lower turbinate

MATERIAL AND METHODS

MATERIAL AND METHODS

Vascular pedicled nasoseptal flap. The arrows show that the rotation must continue to cover the defect.

(A) Nasal graft covering the defect at the ethmoid roof. (B) Endoscopic view of the left nostril – the arrows show where we set the flap.

MATERIAL AND METHODS

Pedicled inferior turbinate flap. (A and B) We marked with electrocautery with the tip of a Colorado needle from the choanal rim to the head of turbinate. (C) Turbinate mucoperiosteal detachment up to the pedicle. (D) The arrow indicates the rotation of the mucoperiosteal flap. (E) Result of the flap (shown by lines) placed in the sellar region after 1 year of evolution.

Both techniques – Tissucol Duo 5.0 ml to fix the flaps – plugged roof to the floor – Surgicel cylinders (haemostatic bandage).

Topical antibiotic drops during this period.

Bedrest for 2 days at a 45 angle – Intravenous amoxicillin/clavulanic acid – after 3 days – discharged – oral antibiotic x 10 days.

Clinical signs of suspected intracranial complications – CT.

Lumbar drain – high-flow fistulas.

Peritoneal ventricular shunt – intracranial hypertension.

MATERIAL AND METHODS

Descriptive analysis performed.

Quantitative variables – mean and standard deviation (SD).

Recurrence rates calculated with 95% confidence intervals.

Kaplan–Meier curves for cumulative survival were compared using the log rank test.

Median and mean times until recurrence were calculated using Kaplan–Meier analysis

p < 0.05 was considered statistically significant.

SPSS software was used.

STATISTICAL ANALYSIS

33 patients – 96.9% low-flow fistulas.26 patients – size of the defects – less than 1x1 cm.17 patients (51.5%) – female.

Mean age – similar for both groups.

45.5% (n = 15) – spontaneous,39.4% (n = 13) – iatrogenically (5 – endoscopic sinus surgery and 8 – neurosurgical process),15.5% (n = 5) – head trauma.

Location – 42.2% – ethmoid roof.

Closure in 26 (78.7%) patients.NF – 22 patients – closure in 19 (86.3%)Free graft – 7 patients (63.6%)

RESULTS

RESULTS

Mean follow-up time – 71.5 months (95% CI, 56.9– 86.1).

2 and 5 years follow-up – success rate – 90% and 81% for NF. 89% and 69% for NG.

Comparing with the long-rank test – no statistically significant differences – p = 0.93, and no associated confounding factors.

one case – lumbar drain used – highflow fistulas.

one case – trephination of the frontal sinus.

On a 2nd occasion – again operated free NG (n = 5) and pedicled NF (n = 4) recurrences with pedicled NF – closed two and two, respectively 90.9% of these at the second attempt.

RESULTS

RESULTS

Only studied cases – operated first time.

Described the results – reoperations using pedicled NF.

Difficult to compare – data consistent with other authors.

Dodson et al – sealed 22 of 29 patients (75.9%) – first operation25 of 29 (86.2%) – second operation.

Kennedy et al – 94.4% closure in 36 patients – first operation (25 months follow-up)

Draf et al – 90% – first operation and 100% – second operation. – 95.7% – first operation – head trauma.

DISCUSSION

Stammberger et al – 94.5% – 72 cases (follow-up – 19–65 months).

Marshall et al – 93% single operation.

Mirza et al – 90% in 72 cases – first operation – 97% – second operation – 99% – third operation

Endoscopic sinus surgery – repeatable technique.

one of the causes – failure – treating both small and large defects in a similar way. Small fistulas – closure rates over 90% – first operation

– 97% for subsequent operations.Defects of >1.5 cm need support to avoid encephalocele in fascia, cartilage or bone.

DISCUSSION

Cannot treat small and large defects similarly.

Not very large defects – some failures avoided – had some kind of support used.

High-flow fistulas – button graft – alternative closure.

Reduce recurrences – different authors – lumbar drain – high-flow fistulas – others reject – risk of cerebral herniation.

Results – similar – other studies – systematically placed lumbar drain both pre and post surgery.

DISCUSSION

Closure – because of surgical sealing – not because a lumbar drain has or has not been put in place.

Intracranial hypertension with CSF leaks – instead of lumbar drain – ventriculoperitoneal shunt – reduce risk of recurrence.

Use of different types of flaps for primary closure can influence the final result.

No statistically significant differences.

One limitations – small sample size – rare pathology.

Most common location – at the level of the ethmoid roof and floor of the anterior cranial fossa.

DISCUSSION

Telera et al – hyperpneumatization in the sphenoid sinus allows development of CSF rhinorrhea – lateral wall.

Two patients – sphenoid hyperpneumatization.

Biochemical diagnosis – β-2-transferrin – immunofixation electrophoresis.

More reliable and cheap method – β-trace protein.

Meco et al – better than β-2-transferrin – should not be used in patients with renal insufficiency or bacterial meningitis – increased in serum and decreased in CSF.

DISCUSSION

Several authors recommend – pedicle flaps.

Better results – no significant differences.

Solyar et al – no standard way – closing defects – base of the cranium.

NGs tend to contract up to 25% of their original size.NFs tend to withdraw to their original position.

Choosing – surgeon’s experience and location and size of the defect.Lack of statistical significance could be due to the small sample size.

Current trend – pedicled flaps – recurrences continue to happen.Anatomic position of the defect, the high CSF pressure, disease that caused it, previous history of radiotherapy, a fistula active at the time of surgery, and migration and retraction of the flaps.

DISCUSSION

Use of NF for primary closure of CSF rhinorrhea did not provide better results than using NG.

Multicenter randomized studies needed.

Not all types of sinonasal CSF require the same surgical technique – depends on the surgeon’s experience, location and size of the defect.

CONCLUSIONS

No conflicts of interest.

Alone are responsible for the content and writing of the paper.

DECLARATION OF INTEREST

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