Download PDF
J Neurol Surg B Skull Base 2023; 84(03): 225-231
DOI: 10.1055/a-1796-7984
Original Article

Characterization of the Saddle Nose Deformity Following Endoscopic Endonasal Skull Base Surgery

Erin E. Anstadt 
1   Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Wendy Chen
1   Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
James O'Brien
2   University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Ilana Ickow
3   Department of Plastic and Reconstructive Surgery, Johns Hopkins Medicine, Baltimore, Maryland, United States
,
Ian Chow
1   Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Madeleine K. Bruce
2   University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
,
Jesse A. Goldstein
4   Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Barton F. Branstetter IV
5   Department of Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Carl Snyderman
6   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Eric W. Wang
6   Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Paul Gardner
7   Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Lindsay Schuster
8   Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Objective The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular.

Setting/Participants This is a retrospective review of 20 adult patients with SND after EEA for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center.

Main Outcome Measures Fifteen measurements related to SND were obtained on pre- and postoperative imaging. Statistical analyses were performed to evaluate differences between pre- and postoperative anatomies.

Results The most common EEA was transsellar. Reconstruction techniques included nine free mucosal grafts alone, eight vascularized nasoseptal flaps (NSFs), one combined free mucosal graft/abdominal fat graft, and one combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection, and nasolabial angle postoperatively. Subgroup analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2 mm, p = 0.039) and increased alar base width (1.2 mm, p = 0.046) postoperatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on postoperative imaging, in contrast to those with functional adenomas who had no measurable significant changes.

Conclusion Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests.

Keywords

saddle nose deformity - endoscopic endonasal approach - nasoseptal flap - functional pituitary microadenoma - nasal deformity


Publication History

Received: 24 January 2022

Accepted: 03 March 2022

Accepted Manuscript online:
14 March 2022

Article published online:
22 April 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Kasemsiri P, Carrau RL, Ditzel Filho LFS. et al. Advantages and limitations of endoscopic endonasal approaches to the skull base. World Neurosurg 2014; 82 (6, Suppl): S12-S21
    CrossrefPubMedGoogle Scholar
  • 2 Snyderman CH, Carrau RL, Kassam AB. et al. Endoscopic skull base surgery: principles of endonasal oncological surgery. J Surg Oncol 2008; 97 (08) 658-664
    CrossrefPubMedGoogle Scholar
  • 3 Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded endonasal approaches. Neurosurg Focus 2005; 19 (01) E8
    CrossrefPubMedGoogle Scholar
  • 4 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
    CrossrefPubMedGoogle Scholar
  • 5 Esposito F, Dusick JR, Fatemi N, Kelly DF. Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Oper Neurosurg (Hagerstown) 2007; 60 (4, suppl 2): discussion 303–304 295-303
    CrossrefPubMedGoogle Scholar
  • 6 Dehdashti AR, Stofko D, Okun J, Obourn C, Kennedy T. Endoscopic endonasal reconstruction of skull base: repair protocol. J Neurol Surg B Skull Base 2016; 77 (03) 271-278
    PubMedGoogle Scholar
  • 7 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
    CrossrefPubMedGoogle Scholar
  • 8 Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 2012; 77 (5-6): 713-724
    CrossrefPubMedGoogle Scholar
  • 9 Morgenstern PF, Ivasyk I, Anand VK, Schwartz TH. The evolution of endoscopic skull base surgery outcomes: defining the edge of the envelope. World Neurosurg 2019; 124: 491-501
    CrossrefPubMedGoogle Scholar
  • 10 Messerer M, De Battista JC, Raverot G. et al. Evidence of improved surgical outcome following endoscopy for nonfunctioning pituitary adenoma removal. Neurosurg Focus 2011; 30 (04) E11
    CrossrefPubMedGoogle Scholar
  • 11 Gallagher MJ, Durnford AJ, Wahab SS, Nair S, Rokade A, Mathad N. Patient-reported nasal morbidity following endoscopic endonasal skull base surgery. Br J Neurosurg 2014; 28 (05) 622-625
    CrossrefPubMedGoogle Scholar
  • 12 Soudry E, Psaltis AJ, Lee KH, Vaezafshar R, Nayak JV, Hwang PH. Complications associated with the pedicled nasoseptal flap for skull base reconstruction. Laryngoscope 2015; 125 (01) 80-85
    CrossrefPubMedGoogle Scholar
  • 13 Awad AJ, Mohyeldin A, El-Sayed IH, Aghi MK. Sinonasal morbidity following endoscopic endonasal skull base surgery. Clin Neurol Neurosurg 2015; 130 (130) 162-167
    CrossrefPubMedGoogle Scholar
  • 14 Glicksman JT, Parasher AK, Brooks SG. et al. Sinonasal quality of life after endoscopic resection of malignant sinonasal and skull base tumors. Laryngoscope 2018; 128 (04) 789-793
    CrossrefPubMedGoogle Scholar
  • 15 Kimple AJ, Leight WD, Wheless SA, Zanation AM. Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate mucosal grafts. Laryngoscope 2012; 122 (09) 1920-1924
    CrossrefPubMedGoogle Scholar
  • 16 Lavigne P, Faden DL, Wang EW, Snyderman CH. Complications of nasoseptal flap reconstruction: a systematic review. J Neurol Surg B Skull Base 2018; 79 (10, suppl 4): S291-S299
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Rowan NR, Wang EW, Gardner PA, Fernandez-Miranda JC, Snyderman CH. Nasal deformities following nasoseptal flap reconstruction of skull base defects. J Neurol Surg B Skull Base 2016; 77 (01) 14-18
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Menick F. Nasal Reconstruction: Art and Practice. Philadelphia: Saunders Elsevier; 2009
    Google Scholar
  • 19 Caicedo-Granados E, Carrau R, Snyderman CH. et al. Reverse rotation flap for reconstruction of donor site after vascular pedicled nasoseptal flap in skull base surgery. Laryngoscope 2010; 120 (08) 1550-1552
    CrossrefPubMedGoogle Scholar
  • 20 Farkas L. Anthropometry of the Head and Face. New York: Raven Press; 1994: 286-287
    Google Scholar
  • 21 Atkins J. Symposium: nasal airway studies. J R Soc Med 1979; 72 (11) 846-855
    PubMedGoogle Scholar
  • 22 Daniel RK. Rhinoplasty: septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg 2007; 119 (03) 1029-1043
    CrossrefPubMedGoogle Scholar
  • 23 Tardy Jr ME, Schwartz M, Parras G. Saddle nose deformity: autogenous graft repair. Facial Plast Surg 1989; 6 (02) 121-134
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Young K, Rowe-Jones J. Current approaches to septal saddle nose reconstruction using autografts. Curr Opin Otolaryngol Head Neck Surg 2011; 19 (04) 276-282
    CrossrefPubMedGoogle Scholar
  • 25 Capone R, Papel I. The Nasal Dorsum: Management of the Upper Two-Thirds of the Nose. 2nd ed.. Baltimore: Lippincott Williams and Wilkins; 2014
    Google Scholar
  • 26 Boccieri A. The crooked nose. Acta Otorhinolaryngol Ital 2013; 33 (03) 163-168
    PubMedGoogle Scholar
  • 27 Soyka MB, Serra C, Regli L, Meier E, Holzmann D. Long-term olfactory outcome after nasoseptal flap reconstructions in midline skull base surgery. Am J Rhinol Allergy 2017; 31 (05) 334-337
    CrossrefPubMedGoogle Scholar