Approaches to the Sella with the Preservation of the Pedicle to the Nasoseptal Flap

Objective The Hadad-Bassagasteguy nasal septal flap (NSF) is the cornerstone of a multilayered skull base reconstruction. As such, the viability of its pedicle is critical to its preservation and role in minimizing postoperative cerebrospinal fluid (CSF) leaks. One drawback to the NSF is the need to harvest it before knowing whether it will be necessary, especially with lesions such as pituitary adenomas. We developed several techniques that focus on the preservation of the pedicle to the NSF, and report on our experiences in this review.

Methods We performed a retrospective chart review of patients diagnosed with pituitary adenomas, and performed a case–control study to compare the success of the Tunnel and 1.5 approaches in preserving the pedicle to the NSF and evaluated the rate of postoperative CSF leaks. The operative time, length of stay, estimated blood loss, and postoperative SNOT-22 scores were also compared.

Results A total of 18 patients (8 patients underwent a Tunnel approach, 10 patients underwent a 1.5 approach) with a pituitary adenoma were identified who needed a NSF as part of the skull base reconstruction. Of these, 17 patients had an intraoperative CSF leak, whereas 1 patient developed a postoperative CSF leak. All patients were successfully treated with a NSF. There were no lumbar drains placed.

The 18 patients were case matched 1:1 to a control cohort who did not develop a CSF leak intraoperatively. There were no significant differences with regard to operative time, estimated blood loss, and length of stay. The postoperative SNOT-22 scores were shown to be significantly higher in patients where the NSF was harvested.

Conclusion The 1.5 and Tunnel approaches that we have previously described are versatile approaches that are effective in preserving the pedicle to the nasoseptal flap and minimizing overall sinonasal morbidity. These approaches obviate the need to harvest the nasoseptal flap prior to tumor resection, and as such should improve sinonasal outcomes.

No conflict of interest has been declared by the author(s).