Salvage endoscopic nasoseptal flap repair of persistent cerebrospinal fluid leak after open skull base surgery

Purpose: Persistent cerebrospinal fluid (CSF) rhinorrhea after open skull base surgery can be challenging to manage due to the risk of meningitis, brain abscess, surgical morbidity associated with revision craniotomy, and the lack of available healthy autologous tissue after failure of a pericranial flap. Given the recent success of the vascularized pedicled nasoseptal flap (PNSF) for reconstruction after endoscopic skull base surgery, we have adopted this technique as a salvage method to treat recalcitrant CSF rhinorrhea after previous open skull base surgery in order to avoid revision craniotomy. To our knowledge, use of the PNSF in this setting has not been previously described in the literature. Methods: A retrospective analysis was performed on 4 patients who underwent endoscopic endonasal PNSF repair of persistent CSF rhinorrhea after having undergone previous open transcranial skull base operation. Pathologies consisted of one sinonasal anterior skull base squamous cell carcinoma, one recurrent petrosal skull base meningioma, and 2 traumatic gunshot wounds to the head. Results: All 4 patients underwent successful repair of CSF rhinorrhea without complications using the salvage endoscopic endonasal PNSF technique after a mean follow-up of 21.5 months. Conclusions: In patients who have undergone previous open skull base surgery as the primary approach, persistent CSF rhinorrhea can be safely repaired using the vascularized PNSF via an endoscopic endonasal approach. This minimally invasive strategy has the advantage of providing new healthy vascularized tissue for skull base reconstruction while avoiding revision craniotomy.