Mark E. Friedel

Endoscopic nasoseptal flap repair of skull base defects: is addition of a dural sealant necessary?

Objective We compared the incidence of postoperative cerebrospinal fluid (CSF) leaks in patients undergoing endoscopic skull base repair with a pedicled nasoseptal flap (PNSF) with or without the addition of a dural sealant. Study Design and Setting Retrospective analysis at a tertiary care medical center. Methods A retrospective analysis was performed at our tertiary care medical center on patients who underwent endoscopic repair of high-flow CSF leaks using a PNSF between December 2008 and August 2011. Repair materials, incidence of postoperative CSF leaks, and demographic data were collected. Results Thirty-two high-flow CSF leaks were repaired with a PNSF alone without dural sealant (group A), and 42 were repaired with a PNSF with the addition of a dural sealant (group B). In group A, there were no postoperative CSF leaks (0%), whereas in group B, there was 1 delayed postoperative CSF leak, resulting in a 2.4% leak rate. The incidence of postoperative CSF leakage was not significantly different between the 2 groups (P = .38). The overall postoperative CSF leak rate was 1.4%. Conclusions The use of dural sealants when performing endoscopic PNSF repair of high-flow CSF leaks is not supported by our data. In addition, this practice may significantly increase surgical cost. We encountered no postoperative CSF leaks in patients with high-flow CSF leaks treated with PNSF alone without dural sealants. Meticulous surgical technique and proper positioning of the PNSF seem to obviate the need for dural sealants during endoscopic skull base reconstruction of high-flow CSF leaks.

Nasoseptal flap repair after endoscopic transsellar versus expanded endonasal approaches: Is there an increased risk of postoperative cerebrospinal fluid leak?†‡

The development of expanded endoscopic endonasal approaches (EEAs) has allowed resection of cranial‐base lesions beyond the sella. One major criticism is an increased risk of postoperative cerebrospinal fluid (CSF) leakage because of the larger skull base defect. We evaluated our experience with vascularized pedicled nasoseptal flap (PNSF) reconstruction and compared the postoperative CSF leak rates between patients undergoing endoscopic transsphenoidal (transsellar) approaches versus expanded EEA (transplanum‐transtuberculum, transcribriform, transclival).

Graduated Endoscopic Multiangle Approach for Access to the Infratemporal Fossa A Cadaveric Study with Clinical Correlates

Objective The infratemporal fossa (ITF) has historically been one of the most difficult regions of the skull base to access surgically. Available open approaches are complex, are associated with high morbidity, and do not always afford optimal visualization. Endoscopic access to the ITF improves visualization for management of many sinonasal and lateral skull base lesions involving this region. The purpose of this study is to evaluate a graduated multiangle approach for endoscopic access to this area using a cadaveric model. Study Design and Setting Cadaveric study at an academic medical center. Methods Endoscopic dissection was performed on a total of 10 sides of 5 fresh cadaveric heads. Four different approaches to the ITF were studied: ipsilateral endonasal, endoscopically assisted Caldwell-Luc, contralateral endonasal via septotomy, and endoscopically assisted Gillies transtemporal. High-quality endoscopic pictures and high-definition videos of each technique were obtained in order to document the differences in access achieved with each approach. Results The combination of the 4 different endoscopic techniques allowed complete access to all areas of the ITF. The endoscopically assisted Caldwell-Luc improved anteroposterior access, the contralateral septotomy approach resulted in excellent far lateral access, and the endoscopically assisted Gillies approach allowed posterosuperior visualization and instrumentation. Conclusion Endoscopic access to the ITF can be accomplished by each of the 4 methods described. A multiangle, graduated approach can provide surgeons the ability to customize surgical access depending on the location of a specific lesion within the ITF.

MODIFIED HEMI-LOTHROP PROCEDURE FOR SUPRAORBITAL FRONTAL SINUS ACCESS: A CADAVERIC FEASIBILITY STUDY

Objective. The endoscopic modified Lothrop procedure (EMLP) is a relatively safe and efficacious advanced approach to access the frontal sinus for recalcitrant disease. There have been limited data specifically addressing those patients with advanced but unilaterally limited and supraorbitally based frontal sinus disease. In this study, the authors propose a modification of the EMLP technique, titled a modified hemi-Lothrop procedure (MHLP), which would limit the dissection of the EMLP to removal of the frontal sinus floor of the unilaterally diseased frontal sinus, thereby sparing the mucosa and natural drainage pathways of the nondiseased contralateral frontal sinus. Study Design and Setting. Cadaveric study at an academic medical center. Methods. A cadaveric dissection with photodocumentation was performed to demonstrate the MHLP and to quantify the accessibility of this approach to far-laterally based frontal sinus disease. Results. The MHLP dissection was shown to provide adequate access to the most distal supraorbital and laterally based aspects of the frontal sinus. Using 3 cadavers, the authors demonstrated and documented the technique of MHLP to access lateral frontal sinus disease from the contralateral nasal cavity via a superior septectomy window. Conclusion. The MHLP was demonstrated to be a feasible approach and alternative to more traditional endoscopic procedures in addressing unilateral frontal sinus disease. This modification may be useful in addressing difficult to access unilateral disease that may otherwise require more extensive resection. This demonstration helps define the accessibility of the lateral frontal sinus via an MHLP and begins to provide estimates of which patients may benefit from this approach.

In-office balloon dilation of the failed frontal sinusotomy.

Frontal sinus (FS) disease management remains one of the most difficult undertaken in endoscopic sinus surgery (ESS). Despite numerous new techniques and instrumentation, FS surgery failures are common. A majority of these failures can be attributed to the difficult and narrow anatomy of the frontal sinus recess (FSR) and significant mucosal trauma during frontal sinusotomies. Revision FS surgery often necessitates further mucosal injury and can be associated with re-scarring of the FSR. Recently, balloon dilation of the sinuses has been introduced as a means to decrease mucosal trauma during ESS. Although still controversial secondary to a lack of definitive evidence and randomized control trials to support its efficacy, proponents of this technology have reported some success with its use. Potential advantages of the in-office use of this technology include avoidance of general anesthesia risks and decreased cost. We describe our in-office experience using this tool in 5 patients who failed conventional frontal sinusotomy.

Modified Hemi-Lothrop Procedure for Supraorbital Frontal Sinus Access: A Case Series

T he lateral recess or supraorbital region of the frontal sinus (FS; pneumatization of the FS over the orbit) is difficult to access endoscopically. Surgical intervention to this region is often limited to external approaches or advanced endoscopic techniques such as the endoscopic modified Lothrop procedure (EMLP). Recently, we described a modification of the EMLP termed the modified hemi-Lothrop procedure (MHLP), which limits the dissection of the EMLP to the ipsilateral diseased FS, thereby sparing the natural drainage pathway of the contralateral nondiseased FS. In this study, we investigate the effectiveness of the MHLP and provide our experience with 15 patients who underwent this technique.

Modified hemi-Lothrop procedure for supraorbital ethmoid lesion access.

The supraorbital ethmoid (SOE) cell is an accessory ethmoid cell in the frontal area that extends into and pneumatizes superolaterally along the orbital plate of the frontal bone. The outflow pathway of the SOE cell can become obstructed, leading to an SOE mucocele. Given their lateral location, SOE lesions are traditionally treated through external approaches, although some authors have advocated treatment through standard endoscopic routes. We present a case of a large, supraorbital ethmoid mucocele treated with a novel modified hemi‐Lothrop procedure (MHLP). This technique provides the benefit of an angulated approach to increase lateral visualization and bimanual, binostril instrumentation through a superior septectomy window.

Modified mini-Lothrop/extended Draf IIB procedure for contralateral frontal sinus disease: a cadaveric feasibility study.

T he endoscopic modified Lothrop procedure (EMLP) and Draf IIB are advanced endoscopic approaches used to access recalcitrant frontal sinus (FS) disease. However, in select cases, anatomic variations may hinder access using these traditional endoscopic approaches. In fact, neither of these techniques specifically addressed patients with unilateral inaccessible FS recesses. We propose a hybrid modification of the EMLP and Draf IIB techniques, which we titled the modified mini-Lothrop procedure (MMLP) or extended Draf IIB procedure to manage FS disease in patients with inaccessible ipsilateral FS recess through a contralateral approach. In contrast to external FS procedures or a combined external trephination and endoscopic approach demonstrated in previous literature, we offer a purely endoscopic means of addressing this select patient population.

Community‐acquired methicillin‐resistant Staphylococcus aureus skull base osteomyelitis with occipital condylar cerebrospinal fluid leak in an immunocompetent patient

Community acquired methicillin‐resistant Staphylococcus aureus (CA‐MRSA) is emerging as an important pathogen in paranasal sinus disease. However, sinonasal CA‐MRSA has not been reported as a source of central skull base osteomyelitis. We report an unusual case of a previously healthy and immunocompetent adult who developed meningitis, central skull base osteomyelitis, and occipital condylar cerebrospinal fluid rhinorrhea from CA‐MRSA sphenoid sinusitis requiring endoscopic surgical repair. This case clearly demonstrates the expanding spectrum of severe infections caused by CA‐MRSA, which requires prompt diagnosis, a high level of suspicion, and appropriate medical and/or surgical management.

Bilateral Olfactory Fossa Respiratory Epithelial Adenomatoid Hamartomas

Respiratory epithelial adenomatoid hamartoma (REAH) is a rare benign nonneoplastic sinonasal lesion that usually presents unilaterally. We report an unusual case of bilateral olfactory fossa REAHs mimicking an olfactory neuroblastoma that originated from the superior aspect of the middle turbinates. To our knowledge, only 1 similar case has been reported to date. Rhinologists and skull base surgeons should be aware of this rare entity to prevent unnecessary radical surgical interventions. Complete removal can be performed using a minimally invasive endonasal endoscopic approach.