Abstract
Surgical approaches to the sphenoid sinus began in the early 20th century as sellar tumors gained recognition because of advances in neurology, pathology, and radiology. Developments in the field of endoscopic surgery have prompted surgeons to attempt endoscope-assisted surgery of the pituitary gland and to use endoscopes in surgery for pituitary tumors and anterior skull base lesions, which have been particularly successful. 1 Access to the sphenoid sinus is the first step in surgery and classically has been described in three ways: transnasal direct, transseptal, and transnasal with removal of the posterior nasal septum. The transnasal direct is preferable when the lesion is unilateral. The transseptal approach is more conservative and leaves the anatomy of the nasal cavity intact. The transnasal approach with removal of the posterior nasal septum may be preferable when the patient has undergone previous septum surgery; this approach also allows concomitant binostril work. 2-4 However, to enable the binostril work, the posterior septal portion must be removed, a procedure that results in a large posterior septal perforation. Septal perforations can cause significant morbidity; associated symptoms include nasal congestion or obstruction, nasal crusting and drainage, and recurrent epistaxis, among other problems. We describe a novel endoscopic transseptal approach using a posterior nasal septal mucosal flap, which allows the surgeon to perform binostril work, cover the skull base defects, and avoid posterior nasal septal perforation. This technique was submitted to and approved by the ethical committee of our institution. SURGICAL TECHNIQUE The surgery is performed under general anesthesia. The patient is in the supine position, with the dorsum elevated approximately 30 degrees. The nasal cavity is decongested with cottonoids soaked in a vasoconstrictor solution. The surgery begins with an infiltration of the nasal septum with a lidocaine 2 percent epinephrine 1:100.000 solution. A classic anterior incision for septoplasty is made, generally at the right side of the nose. A mucoperichondrial/ mucoperiosteal dissection is made at both sides. The posterior part of the nasal septum is removed, saving the inferior portion as a landmark for midline. The sphenoid rostrum and anterior wall of the sphenoid sinus are exposed. The next step is the creation of the flap at one side of the nasal septal mucosa. We perform three incisions: 1) vertical: 2 to 3 cm anterior to the sphenoid rostrum; 2) superior horizontal: 1 to 2 cm below the most superior aspect of the nasal septum; 3) inferior horizontal: 0.5 cm above the nasal floor. These incisions can be completed with scissors or other sharp instruments as necessary, making a mucosal flap that is displaced on the nasal floor (Fig 1). This nasal septal flap preserves the posteriolateral neurovascular pedicle in the sphenopalatine neurovascular bundle. 5 The other side of the
Published Version
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