Non-pedicled vs vascular pedicled nasal flap in repair of cerebrospinal fluid rhinorrhea

J. AGUILAR CANTADOR, A. JURADO-RAMOS, J. GUTIRREZ JODAS, N. MLLER LOCATELLI, E. CANTILLO BAOS & F. MUOZ DEL CASTILLO Department of Otolaryngology-Head and Neck Surgery, Reina Sofa 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.

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.

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.

Nasal endoscopy no rhinoliquorrea chest with head down maneuver electrophoresis of the liquid -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.

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.

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

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.

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.

Descriptive analysis performed.

Quantitative variables mean and standard deviation (SD).

Recurrence rates calculated with 95% confidence intervals.

KaplanMeier 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.

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%)

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.

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 operation 25 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.

Stammberger et al 94.5% 72 cases (follow-up 1965 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.

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.

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.

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

Biochemical diagnosis -2-transferrin immunofixation electrophoresis.

More reliable and cheap method -trace protein. Meco et al better than -2-transferrin should not be used in patients with renal insufficiency or bacterial meningitis increased in serum and decreased in CSF.

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 surgeons 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.

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 surgeons experience, location and size of the defect.

No conflicts of interest.

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