Complications of Nasoseptal Flap Reconstruction: A Systematic Review

Philippe Lavigne; Daniel L. Faden; Eric W. Wang; Carl H. Snyderman

doi:10.1055/s-0038-1668158

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2018; 79(S 04): S291-S299
DOI: 10.1055/s-0038-1668158

WFSBS 2016

Georg Thieme Verlag KG Stuttgart · New York

Complications of Nasoseptal Flap Reconstruction: A Systematic Review

Authors

Philippe Lavigne

¹Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
Daniel L. Faden

¹Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
Eric W. Wang

¹Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
Carl H. Snyderman

¹Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States

Abstract

Objective The nasoseptal flap (NSF) is considered the primary vascularized flap for reconstruction of dural defects with endoscopic endonasal surgery (EES) of the skull base. However, the complications and morbidities associated with this reconstructive flap are poorly understood. This article presents a systematic review of the complications and morbidities related to the use of the NSF in skull base surgery.

Method A systematic review of the literature based on published guidelines was performed to identify potential complications and morbidities related to the NSF. The MEDLINE and Embase databases were searched from January 1, 1950 to February 5, 2018.

Results Twenty-seven articles were identified. Reported complications were as follows: NSF necrosis (4 studies; [0–1.3%]), mucocele formation (5 studies; [0–3.6%]), septal perforation (6 studies, [0–14.4%]), nasal dorsum collapse (2 studies, [0.7–5.8%]), effects on quality of life (QoL) (8 studies), and olfactory loss (11 studies).

Conclusion Although complications associated with the NSF may be underreported in the literature, the NSF appears to be a safe and reliable reconstructive flap in EES of the skull base.

Keywords

systematic review - skull base surgery - nasoseptal flap - complications - reconstruction

Full Text

References

References
1 Hadad G, Bassagasteguy L, Carrau RL. , et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
2 Hirsch O. Successful closure of cere brospinal fluid rhinorrhea by endonasal surgery. AMA Arch Otolaryngol 1952; 56 (01) 1-12
3 Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 2012; 122 (02) 452-459
4 Zanation AM, Carrau RL, Snyderman CH. , et al. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 2009; 23 (05) 518-521
5 Chabot JD, Patel CR, Hughes MA. , et al. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2018; 128 (05) 1463-1472
6 Soyka MB, Serra C, Regli L, Meier E, Holzmann D. Long-term olfactory outcome after nasoseptal flap reconstructions in midline skull base surgery. Am J Rhinol Allergy 2017; 31 (05) 334-337
7 Soudry E, Psaltis AJ, Lee KH, Vaezafshar R, Nayak JV, Hwang PH. Complications associated with the pedicled nasoseptal flap for skull base reconstruction. Laryngoscope 2015; 125 (01) 80-85
8 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
9 Dolci RLL, Miyake MM, Tateno DA. , et al. Postoperative otorhinolaryngologic complications in transnasal endoscopic surgery to access the skull base. Rev Bras Otorrinolaringol (Engl Ed) 2017; 83 (03) 349-355
10 Husain Q, Sanghvi S, Kovalerchik O. , et al. Assessment of mucocele formation after endoscopic nasoseptal flap reconstruction of skull base defects. Allergy Rhinol (Providence) 2013; 4 (01) e27-e31
11 Bleier BS, Wang EW, Vandergrift III WA, Schlosser RJ. Mucocele rate after endoscopic skull base reconstruction using vascularized pedicled flaps. Am J Rhinol Allergy 2011; 25 (03) 186-187
12 Nyquist GG, Anand VK, Singh A, Schwartz TH. Janus flap: bilateral nasoseptal flaps for anterior skull base reconstruction. Otolaryngol Head Neck Surg 2010; 142 (03) 327-331
13 Rowan NR, Wang EW, Gardner PA, Fernandez-Miranda JC, Snyderman CH. Nasal deformities following nasoseptal flap reconstruction of skull base defects. J Neurol Surg B Skull Base 2016; 77 (01) 14-18
14 Shin JH, Kang SG, Kim SW. , et al. Bilateral nasoseptal flaps for endoscopic endonasal transsphenoidal approach. J Craniofac Surg 2013; 24 (05) 1569-1572
15 Jalessi M, Jahanbakhshi A, Amini E, Kamrava SK, Farhadi M. Impact of nasoseptal flap elevation on sinonasal quality of life in endoscopic endonasal approach to pituitary adenomas. Eur Arch Otorhinolaryngol 2016; 273 (05) 1199-1205
16 de Almeida JR, Snyderman CH, Gardner PA, Carrau RL, Vescan AD. Nasal morbidity following endoscopic skull base surgery: a prospective cohort study. Head Neck 2011; 33 (04) 547-551
17 Pant H, Bhatki AM, Snyderman CH. , et al. Quality of life following endonasal skull base surgery. Skull Base 2010; 20 (01) 35-40
18 Upadhyay S, Buohliqah L, Dolci RLL, Otto BA, Prevedello DM, Carrau RL. Periodic olfactory assessment in patients undergoing skull base surgery with preservation of the olfactory strip. Laryngoscope 2017; 127 (09) 1970-1975
19 Rioja E, Bernal-Sprekelsen M, Enriquez K. , et al. Long-term outcomes of endoscopic endonasal approach for skull base surgery: a prospective study. Eur Arch Otorhinolaryngol 2016; 273 (07) 1809-1817
20 Harvey RJ, Winder M, Davidson A. , et al. The olfactory strip and its preservation in endoscopic pituitary surgery maintains smell and sinonasal function. J Neurol Surg B Skull Base 2015; 76 (06) 464-470
21 Chaaban MR, Chaudhry AL, Riley KO, Woodworth BA. Objective assessment of olfaction after transsphenoidal pituitary surgery. Am J Rhinol Allergy 2015; 29 (05) 365-368
22 Kim BY, Kang SG, Kim SW. , et al. Olfactory changes after endoscopic endonasal transsphenoidal approach for skull base tumors. Laryngoscope 2014; 124 (11) 2470-2475
23 Tam S, Duggal N, Rotenberg BW. Olfactory outcomes following endoscopic pituitary surgery with or without septal flap reconstruction: a randomized controlled trial. Int Forum Allergy Rhinol 2013; 3 (01) 62-65
24 Kim SW, Park KB, Khalmuratova R, Lee HK, Jeon SY, Kim DW. Clinical and histologic studies of olfactory outcomes after nasoseptal flap harvesting. Laryngoscope 2013; 123 (07) 1602-1606
25 Rotenberg BW, Saunders S, Duggal N. Olfactory outcomes after endoscopic transsphenoidal pituitary surgery. Laryngoscope 2011; 121 (08) 1611-1613
26 Harvey RJ, Malek J, Winder M. , et al. Sinonasal morbidity following tumour resection with and without nasoseptal flap reconstruction. Rhinology 2015; 53 (02) 122-128
27 Hanson M, Patel PM, Betz C, Olson S, Panizza B, Wallwork B. Sinonasal outcomes following endoscopic anterior skull base surgery with nasoseptal flap reconstruction: a prospective study. J Laryngol Otol 2015; 129 (Suppl. 03) S41-S46
28 Thompson CF, Suh JD, Liu Y, Bergsneider M, Wang MB. Modifications to the endoscopic approach for anterior skull base lesions improve postoperative sinonasal symptoms. J Neurol Surg B Skull Base 2014; 75 (01) 65-72
29 McCoul ED, Anand VK, Schwartz TH. Improvements in site-specific quality of life 6 months after endoscopic anterior skull base surgery: a prospective study. J Neurosurg 2012; 117 (03) 498-506
30 Balaker AE, Bergsneider M, Martin NA, Wang MB. Evolution of sinonasal symptoms following endoscopic anterior skull base surgery. Skull Base 2010; 20 (04) 245-251
31 Guyatt GH, Oxman AD, Vist GE. , et al; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336 (7650): 924-926
32 Atkins D, Eccles M, Flottorp S. , et al; GRADE Working Group. Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches the GRADE Working Group. BMC Health Serv Res 2004; 4 (01) 38
33 Zhang X, Wang EW, Wei H. , et al. Anatomy of the posterior septal artery with surgical implications on the vascularized pedicled nasoseptal flap. Head Neck 2015; 37 (10) 1470-1476
34 Kerr EE, Jamshidi A, Carrau RL. , et al. Indocyanine green fluorescence to evaluate nasoseptal flap viability in endoscopic endonasal cranial base surgery. J Neurol Surg B Skull Base 2017; 78 (05) 408-412
35 Learned KO, Adappa ND, Loevner LA, Palmer JN, Newman JG, Lee JY. MR imaging evaluation of endoscopic cranial base reconstruction with pedicled nasoseptal flap following endoscopic endonasal skull base surgery. Eur J Radiol 2013; 82 (03) 544-551
36 Walsh E, Illing E, Riley KO. , et al. Inaccurate assessments of anterior cranial base malignancy following nasoseptal flap reconstruction. J Neurol Surg B Skull Base 2015; 76 (05) 385-389
37 Park W, Hong SD, Nam DH. , et al. Nasoseptal flap elevation in patients with history of septal surgery: does it increase flap failure or cerebrospinal fluid leakage?. World Neurosurg 2016; 93: 164-167
38 Zanation AM, Carrau RL, Snyderman CH. , et al. Nasoseptal flap takedown and reuse in revision endoscopic skull base reconstruction. Laryngoscope 2011; 121 (01) 42-46
39 Alobid I, Enseñat J, Mariño-Sánchez F. , et al. Impairment of olfaction and mucociliary clearance after expanded endonasal approach using vascularized septal flap reconstruction for skull base tumors. Neurosurgery 2013; 72 (04) 540-546
40 Yoo F, Kuan EC, Bergsneider M, Wang MB. Free mucosal graft reconstruction of the septum after nasoseptal flap harvest: a novel technique using a posterior septal free mucosal graft. J Neurol Surg B Skull Base 2017; 78 (02) 201-206
41 Kimple AJ, Leight WD, Wheless SA, Zanation AM. Reducing nasal morbidity after skull base reconstruction with the nasoseptal flap: free middle turbinate mucosal grafts. Laryngoscope 2012; 122 (09) 1920-1924
42 Caicedo-Granados E, Carrau R, Snyderman CH. , et al. Reverse rotation flap for reconstruction of donor site after vascular pedicled nasoseptal flap in skull base surgery. Laryngoscope 2010; 120 (08) 1550-1552
43 Zeinalizadeh M, Sadrehosseini SM, Barkhoudarian G, Carrau RL. Reconstruction of the denuded nasoseptal flap donor site with a free fascia lata graft: technical note. Eur Arch Otorhinolaryngol 2016; 273 (10) 3179-3182