Abstract
Background The expanded endonasal endoscopic approach provides excellent visualization and access
to midline skull base lesions, albeit with a relatively high risk of postoperative
cerebrospinal fluid (CSF) leakage. We present our experience with the expanded endonasal
endoscopic approach to the skull base in an institution where, previously, a traditional
transsphenoidal approach with a surgical microscope had been used.
Patients We performed a retrospective review to identify patients who underwent expanded endonasal
endoscopic surgery and analyzed demographic, pathological, and operative data with
particular attention to repair of the skull base defects in 55 procedures performed
on 49 patients. We compared the outcomes of 10 primary operations in which we repaired
skull base defects using only autologous or allogeneic tissue grafts and 39 primary
operations in which we used a vascularized mucoperichondrial nasal septal flap with
or without a layered autologous tissue graft.
Results Primary expanded endonasal endoscopic procedures were performed in 49 patients with
sellar pathology (33 pituitary adenomas, 4 Rathke's cleft cysts, 1 pituicytoma, 1
pituitary metastasis) and non-sellar pathology (3 meningiomas, 3 clival chordomas,
1 clival mucocele, 1 craniopharyngioma, and 2 esthesioneuroblastomas). Postoperative
CSF leakage occurred following 5 of the 49 primary operations (10.2%). This occurred
in 2 of 10 primary operations (20.0%) in which the skull base defect was repaired
using only autologous and/or allogeneic tissue grafts, necessitating a total of 3
operative CSF leak repairs in those 2 patients. The remaining 3 postoperative CSF
leaks occurred in the 39 primary operations (7.7%) in which skull base repair was
performed using a mucoperichondrial nasal septal flap, necessitating operative repair
in 2 of those patients.
Conclusion The repair of skull base defects created during expanded endonasal endoscopic surgery
is improved by use of a mucoperichondrial nasal septal flap combined with a layered
autologous tissue graft. When CSF leakage occurs despite nasal septal flap closure,
the site of the leakage may be easier to localize and repair.
Keywords
cerebrospinal fluid leak - endoscopic surgery - expanded endonasal endoscopic approach
- skull base - nasal septal flap - transsphenoidal surgery
