Presentation and Management of Wound Closure Failure after Sphenoclival Expanded Endonasal Surgery: Single Institution Experience

While surgical approaches and techniques of expanded endonasal approach (EEA; surgery have been well described over the past 16 years, data regarding the sequelae of EEA is evolving. Defects if the skull base after EEA are different in size and nature than those that arise from spontaneous CSF leaks. We reviewed the experience at a minimally invasive skull base center with a single OHNS surgeon from 2006 to 2018 and analyzed the closure to help provide clinical insight into diagnosis and management.

Objective: describe the presentation and management of CSF leak after EEA of the sphenoclival axis. Methods: retrospective chart review of single surgeon (OHNS) experience from 2006 to 2018.

Results: Eleven patients were identified in the patient series requiring return to the operating room. Indications for primary surgery included chordoma (three), pituitary adenoma (two), tuberculum meningioma (one), radionecrosis (one), supracellar cyst (one), craniopharyngioma (one), basilar aneurysm (one), epidermoid (one). Nine of eleven surgeries were performed prior to 2012. Malignant etiologies were present in 4/10 cases. The original defect size was a median of 3.75 cm²; (range, 0.05–6.5 cm²) and defects were located in the sella (four), sella clivus (one), clivus (four), clivus planum (one), and planum (one). Nine of 11 defects were categorized as high-flow leaks intraoperatively. Median time to presentation of CSF leak was 20 days (range, 1–542 days). Only three (27%) patients presented within 7 days of surgery and seven (63%) patients presented between 15 to 40 days after surgery.

Presentation: rhinorrhea (eight), meningitis (six), pneumocephalus (one). Overall 10/11 required endoscopic repair and 2/12 required two surgeries. Endoscopic inspection revealed evidence of infection (three), flap necrosis (five), and reversed nasal septal flap (one). CSF leak undetected in operative inspection (one), or repaired with fat graft alone (three), fat graft + inferior turbinate flap (two), inferior turbinate flap alone (one), nasal septal flap + fat graft (three), nasopharyngeal roof mucosa flap + fat graft (one). All CSF leaks were closed without taking down the entire initial repair. Nine of 11 were live at last follow-up. One of 11 Died during admission due to progressive basilar artery aneurysm and 1 of 11 died due to recurrence of malignant disease at 6 months.

Conclusion: The majority of post EEA wound failures present between 15 to 40 days in our experience with either rhinorrhea of clear fluid or signs of meningitis. The majority of cases occurred prior to 2012 after which the authors changed their closure techniques. The majority of closure failures (63%) occur outside the sella reflecting the direct relation to intracranial cisterns. Operative repair is the treatment of choice and involved sealing the defect and using a vascularized flap in the majority of cases (63%), although fat graft alone sufficed in two-thirds of cases. Correct placement of vascularized flap is essential and we now mark the nonepithelialized surface upon flap elevation. Knowledge of alternate flaps is important when the NSF is no longer available.