This text, edited by two fellowship-trained rhinologists and two fellowship-trained neurotologists, represents an up-to-date comprehensive resource for any clinician or scientist involved in skull base reconstruction. Each chapter is written by a “super specialist” who has a clinical and/or academic focus in skull base pathologies and reconstruction. The first section is dedicated to basic principles, anatomy, physiology, imaging and anesthetic considerations. The second and third sections discuss pathological processes that lead to cerebrospinal fluid leaks and the need for skull base reconstruction within the anterior and lateral skull base, respectively. The fourth and fifth sections focus on anterior and lateral skull base reconstruction, respectively, with attention to reconstruction techniques and strategies for managing each defect type. The sixth section comprehensively reviews postoperative care and management strategies, where there is high variability and limited evidence, and is intended to present multiple perspectives that each carry merit. The final section highlights developments, research and emerging ideas regarding this ever-growing topic.
Previous to this, there had been no book dedicated to this highly important and emerging topic that really challenges even the best of surgeons to this day. The intended audience of Skull Base Reconstruction includes skull base surgeons, otolaryngologists, neurosurgeons, neurologists, ophthalmologists, radiologists, emergency medicine physicians, trauma surgeons, and trainees and students in all of those areas.
Author(s): Edward C. Kuan, Bobby A. Tajudeen, Hamid R. Djalilian, Harrison W. Lin
Publisher: Springer
Year: 2023
Language: English
Pages: 485
City: Cham
Foreword
References
Preface
Contents
Part I: Anatomy, Physiology, and General Principles
Chapter 1: Anterior Skull Base Anatomy
Introduction
Nasal Cavity
Paranasal Sinuses
Orbit
Ventral Skull Base
Conclusion
References
Chapter 2: Lateral Skull Base Anatomy
Osseous Anatomy of the Lateral Skull Base
Anatomy of the Auricle and External Canal
Anatomy of the Middle Ear and Eustachian Tube
Anatomy of the Inner Ear
Anatomy of the IAC, Jugular Foramen, and Petrous Apex
Anatomy of the Middle Cranial Fossa
Anatomy of the Posterior Cranial Fossa
Anatomy of the Infratemporal Fossa
References
Chapter 3: CSF Physiology and Intracranial Pressure
Introduction
CSF Production
CSF Contents
CSF Circulation
Ventricular Anatomy
Lateral Ventricles
Third Ventricle
Fourth Ventricle
Subarachnoid Space
Basal Cisterns
CSF Resorption
Venous Sinuses
Lymphatics
Perivascular Pathway
Pathology
Altering Brain
Altering Blood
Altering CSF
Production
Circulation
Resorption
Conclusion
References
Chapter 4: Diagnosis of CSF Leak
Introduction
History and Physical Exam
Traumatic CSF Leak
Spontaneous CSF Leak
Neoplastic CSF Leak
Labs: Halo Sign, Beta-2 Transferrin, Beta-Trace Protein
Fluorescein
Complications: Meningitis and Pneumocephalus
References
Chapter 5: Imaging for Detection of CSF Leaks
Introduction
Diagnostic Techniques
Computed Tomography
Magnetic Resonance Cisternography
Contrast-Enhanced Cisternography
Nuclear Medicine Cisternography
Imaging Findings of CSF Leak
Traumatic CSF Leaks
Iatrogenic CSF Leaks
Secondary CSF Leaks
Spontaneous CSF Leaks
Pitfalls and Mimics
References
Chapter 6: Conservative and Medical Therapy for Cerebrospinal Fluid Leaks
Introduction
Indications for Medical Management
Medical Management Options
Bed Rest/Sinus Precautions
Stool Softeners
Antibiotics
Diuretic and Other Medical Options
Future Directions and Other Considerations
References
Chapter 7: Cerebrospinal Fluid Diversion
External Ventricular Drains
Lumbar Drains
Shunts
Cerebral Venous Sinus Stenting
References
Chapter 8: Anesthesia Considerations in Skull Base Reconstruction
Preoperative Evaluation
History of Present Illness
Medical History
Cardiovascular
Airway and Pulmonary
Endocrine
Functional (Hormone Secreting) Tumors
Growth Hormone
Adrenocorticotropic Hormone (ACTH)
Thyroid Secreting Hormone
Prolactin
Nonfunctional Tumors
Hypopituitarism
Visual Defects
Laboratory
Anesthetic Management
Premedication
Induction
Airway Planning
Ventilation
Transsphenoidal Approach
Retrosigmoid Approach
Monitors
Arterial Blood Pressure
Central Venous Pressure
Urine Output
Lumbar Drain
Vascular Access
Positioning
Supine
Lateral
Sitting
Prone
Anesthetic Choice
Blood Pressure and Fluid Management
Analgesia
Antiemetic Plan
Unique Considerations
Transsphenoidal Approach
Intranasal Pathway
Sella Position
Bleeding
Reduction of ICP
Neuroprotection
Venous Air Embolism
Emergence
Extubation Criteria
Neurologic
Airway and Pulmonary
Cardiovascular
Normothermia
Transsphenoidal Approach
How to Handle Failed Extubation
Postoperative Care
Monitoring
Pain
Nausea
Complications
Neurologic
Pulmonary
Bleeding
CSF Leak
Endocrine
Disposition
Intensive Care Unit (ICU)
Step Down Unit
Recommended Reading
Chapter 9: Allografts and Materials in Skull Base Reconstruction
Introduction
Autologous Grafts
Fat
Fascia Lata
Bone
Free Mucosa
Tissue Glue
Serum Albumin-Derived Sealants
Fibrin-Derived Sealants
PEG-Derived Sealants
Homologues and Xenografts
Duragen, Alloderm, and Collagen Matrix
Gelfoam, Surgiflo, Floseal
Resorbable Plates
Packing
Biodesign and Other Impermeable Grafts
Conclusions
References
Part II: Anterior Skull Base Pathology
Chapter 10: Traumatic and Iatrogenic CSF Leaks
Introduction
Non-iatrogenic Traumatic CSF Leaks
Pathophysiology, Epidemiology, and Diagnosis
Management of Non-iatrogenic Traumatic CSF Leaks
Iatrogenic CSF Leaks
Pathophysiology, Epidemiology, and Diagnosis
Management of Iatrogenic CSF Leaks
Summary
References
Chapter 11: Spontaneous CSF Leaks and Encephaloceles
Introduction
Preoperative Management
Radiographic Features
Empty Sella
Orbital Findings
Enlargement of Meckel’s Cave
Transverse Venous Sinus Stenosis
Meningoceles and Meningoencephaloceles
Skull Base Attenuation and Arachnoid Pits
Sternberg’s Canal Is Not Related to Spontaneous CSF Leaks
Surgical Management
Postoperative Management
Long-Term Medical Management
Alternative Strategies: Dural Venous Stenting
Conclusion
References
Chapter 12: Congenital Encephaloceles
Introduction
Epidemiology
Etiology and Pathophysiology
Classification
Clinical Presentation
Differential Diagnosis and Workup
Differential Diagnosis
Workup
Additional Workup
Treatment
Prognosis
Conclusion
References
Chapter 13: Anterior Skull Base Surgical Approaches
Introduction
Sagittal Plane
Transfrontal
Transcribriform
Transsphenoidal
Transplanum/Tuberculum (Suprasellar)
Transsellar
Transclival
Superior Clival Approach
Middle Clival Approach
Lower Clival Approach
Transodontoid
Coronal Plane
Medial Supraorbital
Transorbital
Transpterygoid
Considerations in Pediatric Patients
Size and Tight Working Spaces
Pneumatization of Paranasal Sinuses
Sphenoid Sinus
Ethmoid Sinus
Maxillary Sinus
Frontal Sinus
Craniocervical Junction
Reconstruction of the Skull Base and Postoperative Care
Discussion
Conclusion
References
Part III: Lateral Skull Base Pathology
Chapter 14: Traumatic and Iatrogenic CSF Leaks
Temporal Fracture
Penetrating Trauma
Iatrogenic Injury
References
Chapter 15: Spontaneous CSF Leaks and Encephaloceles
Introduction
Presenting Signs and Symptoms
Risk Factors for sCSF Leaks
Role of Obesity
Idiopathic Intracranial Hypertension
Obstructive Sleep Apnea
Congenital Defects
Workup
Laboratory Findings
CT
MRI
Long-Term Follow-Up and Management
Meningitis Risk
Conclusions
References
Chapter 16: Lateral Skull Base Surgical Approaches
Middle Cranial Fossa Approach
Incision and Flap Elevation
Craniotomy
Repair of Skull Base Defect
Translabyrinthine Approach
Simple Mastoidectomy and Facial Nerve Identification
Postauricular Labyrinthectomy
Repair of Skull Base Defect
Transmastoid Approach
Postauricular Cortical Mastoidectomy
Repair of Tegmen Defect
Transcanal Approach
Conclusion
References
Part IV: Anterior Skull Base Reconstruction
Chapter 17: Free Graft Techniques for Skull Base Reconstruction
Introduction
Terminology for CSF Leak Repair
Free Graft Options and Physiology
Free Graft Physiology
Mucosal Grafts
Fat Grafts and Bath-Plug Technique
Fascia
Bone
Gasket-Seal Technique
Allografts and Xenografts
Adjunctive Techniques
Packing
Lumbar Drains
Tissue Sealants
Overall Success Rates of Free Graft Techniques
How Do You Choose?
Conclusions
References
Chapter 18: Local Vascularized Pedicled Flaps for Skull Base Reconstruction
Introduction
Evaluation
Intraoperative Considerations
Nasoseptal Flap
Inferior Turbinate and Lateral Nasal Wall Flap
Middle Turbinate Flap
Extranasal Flaps
Outcomes
References
Chapter 19: Extracranial Flaps for Skull Base Reconstruction
Pericranial Flap
History
Anatomy
Surgical Steps
Outcomes
Conclusion
Temporoparietal Fascia Flap
Other Experimental Flaps
Pedicled Palatal Flap
Facial Artery Buccinator Flap
Occipital Galeo-pericranial Flap
References
Chapter 20: Free Flap Reconstruction of Anterior Skull Base Defects
Anatomic Considerations and Defect Classification
Goals of Reconstruction
Reconstructive Technique and Tissue Selection
Radial Forearm Free Flap
Anterolateral Thigh Free Flap
Rectus Abdominis Free Flap
Latissimus Dorsi Free Flap
Subscapular System
Postoperative Considerations
Outcomes and Limitations
References
Chapter 21: Reconstruction of Frontal and Ethmoid Defects
Introduction
Obliteration
Cranialization
Direct Repair for Frontal Sinus Posterior Table Defects
Management of the Frontal Recess
Endoscopic Approaches
Endoscopic-Assisted Techniques
Supraorbital Ethmoid Pathology
Reconstructive Ladder
Conclusion
References
Chapter 22: Reconstruction of Sphenoid Defects: Lateral Recess, Sellar, Tuberculum, and Planum Defects
Introduction
Materials for Skull Base Repair (Divided by Reconstruction Layer)
Dural Reconstruction
Bone Reconstruction
Mucosal Reconstruction
Tissue Glues
Surgical Reconstruction (Divided by Location)
Reconstruction of Sellar Defects
Reconstruction of Tuberculum and Planum Defects
Reconstruction of Lateral Recess Defects
Conclusion
References
Chapter 23: Reconstruction of Clival and Craniocervical Junction Defects
Introduction
Applied Anatomy and Reconstructive Goals
Key Surgical Anatomy
Principles and Challenges of Clival and Craniocervical Junction Reconstruction
Review of Reconstructive Techniques
Multilayered Reconstruction Paradigm
Free Mucosal Grafts
Local Pedicled Flaps: Nasoseptal Flap, Lateral Nasal Wall Flap, and Rhinopharyngeal Flap
Vascularized Regional Flaps: Pericranial Flap, Temporoparietal Fascia Flap, and Palatal Flap
Microvascular Free Tissue Transfer
Perioperative Management
Packing
Antibiotics
Lumbar Drain
Conclusions
References
Part V: Lateral Skull Base Reconstruction
Chapter 24: Management of Cerebrospinal Fluid Leaks During Otologic Surgery
Introduction
Preoperative Considerations
Role of Imaging and Avoidance
Perioperative Discussion
Operative Repair of Congenital and Acquired CSF Leak
General Considerations
Avoidance and Detection of Intraoperative CSF Leaks
Management of Intraoperative CSF Leak
Soft Tissue Work
Repair of Small Defects
Repair of Large or Multiple Defects
Middle Fossa Craniotomy for Repair of Tegmen Defects
Repair of Mastoid Defects
The Canal Wall Down Mastoid Cavity
Eustachian Tube Obliteration and Ear Canal Closure
Cerebrospinal Fluid Leaks from the Inner Ear
Middle Ear CSF Leaks
Postoperative Considerations
References
Chapter 25: General Repair Principles Following Posterior Cranial Base Surgery
Introduction
Closure After Middle Cranial Fossa Approach
Closure After Retrosigmoid or Lateral Suboccipital Approach
Closure After Translabyrinthine Approach
Outcomes for Reconstruction of Posterior Skull Base Defects
Middle Cranial Fossa Approach
Retrosigmoid or Lateral Suboccipital Approach
Translabyrinthine Approach
Conclusion
References
Chapter 26: Reconstruction of the Middle Cranial Fossa Floor
Introduction
Surgical Techniques
Middle Fossa Craniotomy for Repair of Spontaneous Tegmen Defects With or Without Meningoencephalocele and CSF Leak
Middle Fossa Craniotomy for Superior Canal Dehiscence Repair
Transmastoid Repair of Posterior and Lateral Tegmen Defects
Combined Transmastoid and Middle Fossa Approach
Modified Approaches
Endoscopic Assisted Middle Fossa Craniotomy Approach
Keyhole Middle Fossa Approach
3D Printed Implants for Lateral Skull Base Repair
Materials
Perioperative Considerations
Conclusion
References
Chapter 27: Reconstruction of Large Temporal Bone Defects
Introduction
Anatomy of Lateral Skull Base
Important Considerations for Reconstruction
Reconstructive Methods
Local Tissue Flaps
Regional Flaps
Free Flaps
Approach to Reconstruction
References
Part VI: Postoperative Care
Chapter 28: Postoperative Management Following Skull Base Reconstruction
Introduction
Skull Base Reconstruction Intranasal Bolstering
Sealant Layer
Nasal Packing
Postoperative Imaging
Skull Base Precautions
Antibiotics
Lumbar Drain
Debridement
References
Chapter 29: Management of the Postoperative Leak
Introduction
Patient Characteristics
Obesity
OSA
Radiation Exposure
Revision Surgery
Surgical Characteristics
Surgical Subsite
Sella Turcica
Parasellar/Suprasellar
Anterior and Posterior Cranial Fossa
Technical Errors
Identification and Localization of Postoperative CSF Leak
Physical Exam
Laboratory Investigation
β-Trace Protein
β2-Transferrin
Imaging
High-Resolution Computed Tomography
Magnetic Resonance Imaging
Magnetic Resonance Cisternography
Computed Tomography Cisternography
Radionuclide Cisternography
Intrathecal and Topical Fluorescein
Conservative Measures/Surgical Adjuncts
Lumbar Drain
Medical Adjuncts
Surgical Treatment of Postoperative CSF Leak
Conclusion/Summary
References
Chapter 30: Other Complications Following Skull Base Reconstruction
Introduction
Tension Pneumocephalus
Presentation and Diagnosis
Management
Orbital Complications
Intracranial Bleeding
Carotid Injury
Other Arterial and Vascular Injury
Sinonasal Morbidity Following ESBS
Postoperative Sinonasal Quality of Life
Nasal Structural Changes
Sinusitis
Conclusion
References
Chapter 31: Outcomes of Anterior Skull Base Reconstruction
Introduction
Avascular Grafts
Vascularized Intranasal Flaps
Locoregional Flaps
Free Tissue Transfer
Quality of Life Outcomes
Conclusion
References
Chapter 32: Outcomes of Lateral Skull Base Reconstruction
Introduction
Outcomes for Reconstruction of Lateral Skull Base Defects
Transmastoid Approach
Overview
Outcomes
Take Home Message
Middle Cranial Fossa Approach
Overview
Outcomes
Take Home Message
Combined Approach
Overview
Outcomes
Take Home Message
Petrosectomy with Middle Ear Obliteration
Overview
Outcomes
Take Home Message
Associated Treatments and Management of the Intracranial Hypertension
Conclusion
Reconstruction of the Lateral Skull Base After Accessing the Cerebellopontine Angle
Retrosigmoid Approach
Overview
Outcomes
Take Home Message
Translabyrinthine Approach
Overview
Outcomes
Take Home Message
Middle Cranial Fossa Approach
Overview
Outcomes
Take Home Message
Locoregional and Free Flaps
Overview
Outcomes
Take Home Message
Conclusion
References
Chapter 33: Medicolegal Issues in Skull Base Reconstruction
Informed Consent
Litigation
Tips to Minimize Risk
References
Part VII: Future Applications
Chapter 34: Emerging Developments in Skull Base Reconstruction
Laser Tissue Welding
Endoscopic CNS Drug Delivery
Point-of-Care CSF Detection
Indocyanin Green in Skull Base Surgery and Reconstruction
Wound Healing Models in Skull Base Reconstruction
Biomechanical Models for Skull Base Reconstruction
Training Through Simulations and 3D Printed Models
References
Index
