Pratik A. Shukla

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery.

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

Readability Assessment of Internet-Based Patient Education Materials Related to Facial Fractures

Various professional societies, clinical practices, hospitals, and health care‐related Web sites provide Internet‐based patient education material (IPEMs) to the general public. However, this information may be written above the 6th‐grade reading level recommended by the US Department of Health and Human Services. The purpose of this study is to assess the readability of facial fracture (FF)‐related IPEMs and compare readability levels of IPEMs provided by four sources: professional societies, clinical practices, hospitals, and miscellaneous sources.

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).

High-resolution computed tomography analysis of the prevalence of onodi cells†‡

Onodi cells are the posterior‐most ethmoid air cells that lie superior to the sphenoid sinus. Identification of these cells is essential prior to endoscopic sinus and skull base surgery due to their intricate relationship with the optic nerves and carotid arteries, which may lead to deleterious complications. In this study, high‐resolution computed tomography (HRCT) scans from 170 adult‐patients were analyzed by two independent observers for the presence of Onodi cells.

Triple-Layer Reconstruction Technique for Large Cribriform Defects After Endoscopic Endonasal Resection of Anterior Skull Base Tumors

Endoscopic endonasal transcribriform (EET) resection of anterior skull base (ASB) tumors results in large defects that may extend the entirety of the cribriform plate. Endoscopic repair of these cribriform defects can often be challenging. We describe our reconstruction technique for large ASB defects after EET resection of ASB tumors. This triple‐layer technique is comprised of autologous fascia lata, acellular dermal allograft, and a vascularized pedicled nasoseptal flap (PNSF). The technique is described and postoperative cerebrospinal fluid (CSF) leak rate is evaluated.

High-Resolution Computed Tomography Analysis of Variations of the Sphenoid Sinus

Purposeu2003The sphenoid sinus is a complex structure with key variations that are important for endoscopic parasellar approaches. In this study, high-resolution computed tomography (HRCT) scans were analyzed for the frequency of these variations. Methodsu2003A retrospective radiographic analysis was conducted on patients undergoing HRCT between July 2008 and September 2010. Resultsu2003Sphenoid sinus pneumatization was defined as conchal, presellar, sellar, and postsellar based on pneumatization relative to the anterior and posterior face of the sella. The distribution ranged from 1.8%, 7.3%, 47.6%, and 43.3%, respectively. We found a greater preponderance of sellar and postsellar variation than previously reported. No differences were found in regard to age, gender, and ethnicity (African American, Caucasian, Asian, and Hispanic) (pu2009>u20090.05). The prevalence of optic nerve, maxillary nerve, and internal carotid artery protrusion was 26.1%, 25.9%, and 28.2%, respectively, and dehiscence was 2.1%, 7.4%, and 2.9%, respectively. Accessory septae were present in 43.5% of cases. A lateral recess was identified in 72.4% and clinoid pneumatization in 20% of patients. Conclusionu2003This study demonstrates a greater prevalence of sphenoid sinus pneumatization and variations than previously reported. This has important implications in terms of preparation and anticipation of possible variations to avoid complications.

Assessment of frontal lobe sagging after endoscopic endonasal transcribriform resection of anterior skull base tumors: is rigid structural reconstruction of the cranial base defect necessary?

The endoscopic endonasal transcribriform approach (EETA) is a viable alternative option for resection of selected anterior skull base (ASB) tumors. However, this technique results in the creation of large cribriform defects. Some have reported the use of a rigid substitute for ASB reconstruction to prevent postoperative frontal lobe sagging. We evaluate the degree of frontal lobe sagging using our triple‐layer technique [fascia lata, acellular dermal allograft, and pedicled nasoseptal flap (PNSF)] without the use of rigid structural reconstruction for large cribriform defects.

Challenges and surgical nuances in reconstruction of large planum sphenoidale tuberculum sellae defects after endoscopic endonasal resection of parasellar skull base tumors

Endoscopic endonasal transplanum transtuberculum (EETT) resection of parasellar skull base (SB) tumors often results in large SB defects with intraoperative high‐flow cerebrospinal fluid (CSF) leaks. Reconstruction of these defects can be challenging because of the large defects size, communication with the suprasellar cistern, and close proximity to the optic nerves and chiasm. Recent studies have postulated that transplanum defects may be associated with increased postoperative CSF leakage. We review our experience with reconstruction of transplanum defects after EETT resection of parasellar SB tumors. Challenges encountered during these repairs and our operative nuances for successful reconstruction are discussed.

Early harvesting of the vascularized pedicled nasoseptal flap during endoscopic skull base surgery

PURPOSEnThe vascularized pedicled nasoseptal flap (PNSF) represents a successful option for reconstruction of large skull base defects after expanded endoscopic endonasal approaches (EEA). This vascularized flap can be harvested early or late in the operation depending on the anticipation of high-flow CSF leaks. Each harvesting technique (early vs. late) is associated with different advantages and disadvantages. In this study, we evaluate our experience with early harvesting of the PNSF for repair of large skull base defects after EEA.nnnMETHODSnA retrospective review was performed at a tertiary care medical center on patients who underwent early PNSF harvesting during reconstruction of intraoperative high-flow CSF leaks after EEA between December 2008 and March 2012. Demographic data, repair materials, surgical approach, and incidence of PNSF usage were collected.nnnRESULTSnEighty-seven patients meeting the inclusion criteria were identified. In 86 procedures (98.9%), the PNSF harvested at the beginning of the operation was used. In 1 case (1.1%), the PNSF was not used because a high-flow intraoperative CSF leak was not encountered. This patient had recurrence of intradural disease 8months later, and the previously elevated PNSF was subsequent used after tumor resection.nnnCONCLUSIONnBased on our data, a high-flow CSF leak and need for a PNSF can be accurately anticipated in patients undergoing EEA for skull base lesions. Because of the advantages of early harvesting of the PNSF and the high preoperative predictive value of CSF leak anticipations, this technique represents a feasible harvesting practice for EEA surgeries.

Readability assessment of internet-based patient education materials related to uterine artery embolization.

PURPOSEnTo determine the readability of Internet-based patient education materials (IPEMs) created by United States hospitals and universities and clinical practices and miscellaneous health care-associated Web sites regarding uterine artery embolization (UAE) as a marker for IPEMs in general.nnnMETHODS AND METHODSnTwo hundred unique Web sites were evaluated for patient-related articles on UAE. Web sites produced by US hospitals and universities and clinical practices, as well as miscellaneous health care-associated Web sites meeting the Health on the Net Foundation Code of Conduct criteria were included in the database. By using mathematical regression algorithms based on word and sentence length to quantitatively analyze reading materials for language intricacy, readability of 40 UAE-related IPEMs was assessed with four indices: Flesch-Kincaid Grade Level (FKGL), Flesch Reading Ease Score (FRES), Simple Measure of Gobbledygook (SMOG), and Gunning Frequency of Gobbledygook (GFOG). Scores were evaluated against national recommendations, and intergroup analysis was performed.nnnRESULTSnNone of the IPEMs were written at or below the sixth-grade reading level, based on FKGL. The mean readability scores were as follows: FRES, 43.98; FKGL, 10.76; SMOG, 13.63; and GFOG, 14.55. These scores indicate that the readability of UAE IPEMs is written at an advanced level, significantly above the recommended 6th grade reading level (P<.05) determined by the United States Department of Health and Human Services.nnnCONCLUSIONSnIPEMs related to UAE generated by hospitals, clinical practices, and miscellaneous health care-associated Web sites are written above the recommended sixth grade level. IPEMs for other disease entities may also reflect similar results.