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Nasoseptal flap closure of the eustachian tube for recalcitrant cerebrospinal fluid rhinorrhea
Author(s) -
Patel Vishal S.,
Choby Garret W.,
Thamboo Andrew,
Blevins Nikolas H.,
Hwang Peter H.
Publication year - 2018
Publication title -
the laryngoscope
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.181
H-Index - 148
eISSN - 1531-4995
pISSN - 0023-852X
DOI - 10.1002/lary.26988
Subject(s) - otorhinolaryngology , medicine , rhinology , head and neck surgery , general surgery , surgery
Recalcitrant cerebrospinal fluid (CSF) rhinorrhea after vestibular schwannoma surgery can be a challenging complication. CSF rhinorrhea can occur following retrosigmoid, middle fossa, or translabyrinthine approaches with approximately equal frequency, and represents a dural breach of CSF transmitted via the eustachian tube (ET) to the nasal cavity. Many postoperative CSF leaks can be successfully managed with conservative measures, such as bedrest and lumbar drain placement. However, as many as 41% ultimately require surgical intervention. In the absence of serviceable residual hearing, the first-line surgical approach typically involves transotic external auditory canal (EAC), middle ear, and ET obliteration with fat, muscle, and/or bone wax. Second-line treatment for refractory cases may include additional mastoid obliteration or ventriculoperitoneal (VP) shunt placement. For intractable cases of CSF rhinorrhea, endoscopic transnasal techniques for ET closure have also been introduced, including cauterization of the ET orifice, suture closure, closure with acellular dermal matrices, or combinations thereof. However, these methods have proven to have variable levels of success. The pedicled nasoseptal flap (NSF) was first described in 2006 for closure of anterior skull base defects. Based on the posterior septal branch of the sphenopalatine artery, the NSF offers significant advantages over traditional free graft techniques, including preserved vascularity, a broad anatomic reach, and a large potential area of coverage. The NSF has become the workhorse reconstructive technique for repair of skull base defects in endoscopic anterior skull base surgery, decreasing postoperative CSF leak rates from greater than 20% to less than 5%. Here, we describe the application of the NSF for endoscopic endonasal closure of the ET for recalcitrant CSF rhinorrhea following lateral skull base surgery for vestibular schwannoma.