Reconstruction Following EEA: A 0.5% CSF Leak Rate in 200 Consecutive Cases

Abstract

Introduction: Reconstruction of the ventral skull base after the Expanded Endonasal Approach (EEA) remains a controversial issue. The development of the pedicled nasoseptal flap (NSF) has been a seminal event in the maturation of EEA, resulting in a marked reduction in cerebrospinal fluid (CSF) leak rates after the procedure. However, other reconstructive options exist, including the use of non-vascularized tissue such as autografts of fat or fascia lata, homografts and tissue adhesives. In addition, many centers now use a hybrid approach, reserving the use of the NSF for high risk cases, and using non-vascularized reconstructions for low risk situations or when the NSF is unavailable because of previous resections or tumor involvement. Our group has routinely used the NSF when available for all EEA cases, with resections of the nasopharynx and drainage of skull base infections and cholesterol granulomas being the most notable exceptions. In addition, we have used other vascularized reconstructions (including the lateral vault flap and, in one case, free tissue transfer) in situations where the NSF is unavailable. This paper will report on our protocol for ventral skull base reconstruction after EEA and examine our CSF leak rate over our last 200 consecutive cases.