Complications of Endoscopic Skull Base Surgery

4. Transclival


– This approach may lead to communication between the nose and the prepontine cistern, resulting in high-flow CSF rhinorrhea.


– Similar to the transtuberculum approach, postoperative CSF rhinorrhea is minimized by multilayered reconstruction and possible addition of a lumbar drain.


– Postoperative CSF rhinorrhea rates as high as 25% to 33% are reported following resection of clival malignancies.


• Prevention and management of CSF leaks


1. Grafts


– Useful for small, low-flow defects


– Graft options include bone, cartilage, mucosa, fat, fascia, or acellular tissue matrix.


– The grafts can be used as a simple onlay or as a combined inlay/onlay.


– The gasket seal is a particularly effective combination graft that includes a rigid inlayed buttress with a soft-tissue scaffold. which is itself both an inlay and onlay graft.


2. Vascularized flaps


– Options include the nasoseptal flap, inferior turbinate flap, and the pericranial flap.


– For large or high-flow defects, vascularized flaps decrease postoperative CSF rhinorrhea rate by approximately 50%.


– The nasoseptal flap is the most frequently used vascularized flap, and is based on the septal branch of the sphenopalatine artery.


3. Lumbar drains


– Benefits of lumbar drainage include diversion of CSF away from the repair site, ability to instill fluorescein to look for leak, and access for postoperative intracranial pressure monitoring.


– Risks of lumbar drain include headache, infections (cellulitis, meningitis, ventriculitis), tension pneumocephalus, subdural hemorrhage, and brain herniation.


– Given the risks of lumbar drainage and proven efficacy of current endoscopic skull base repairs such as the nasoseptal flap, routine lumbar drainage following repair of intra-operative CSF leak is not recommended.


– Lumbar drains may be useful as a supplement to multilayered reconstruction in the following circumstances:


a. Early postoperative CSF leak


b. High-flow leak areas such as the clivus


c. Revision surgery with prior leak


d. Radiation history


e. Large or complex defects


Vascular Injury


Posterior Septal Artery


• Contributes to the majority of post-operative arterial bleeds


• This branch of the sphenopalatine artery is located inferior to the sphenoid os and splits into an inferior and superior branch prior to entering the septum.


• Prevention of vessel injury:


1. Careful inferior mobilization of this mucosa (rostrum and posterior septum) during sphenoidotomy


2. Prophylactic partial nasoseptal flap elevation (“rescue flap” to prevent injury to the artery during procedure


• Prophylactic cautery of the vessel is not recommended since it is critical for reconstruction of skull base defects.


Anterior and Posterior Ethmoidal Arteries


• Injury to these arteries is most often seen in the transcribriform approach.


• Arterial injury may be followed by retraction into the orbit with resultant rapid development of orbital hematoma, rise in intra-orbital pressure, optic nerve ischemia, and subsequent blindness.


• A slower developing orbital hematoma may also develop from venous bleeding from orbital fat or extra-ocular muscle injury.


• Prevention is accomplished by identification and cautery of arteries during the approach, and extreme care when removing the lamina papyracea or periorbita.


• Early signs of orbital hematoma include preseptal edema, ecchymosis, and proptosis.

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Jul 20, 2019 | Posted by in OTOLARYNGOLOGY | Comments Off on Complications of Endoscopic Skull Base Surgery
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