Minimally Invasive Pericranial Flap for Reconstruction after Endonasal Endoscopic Surgery of 30 Consecutive Patients

Objectives/Hypothesis: The introduction of intranasal pedicled flaps has reduced the incidence of postoperative cerebrospinal fluid (CSF) leaks to less than 5%. Nevertheless, in malignant tumors those flaps are not always available because of nasal septum invasion. Minimally invasive pericranial flaps (PCF) are associated with minimal adverse effects and good cosmetic appearance. In spite of that, there are only a few reports of this reconstructive technic limited to short surgical series and radio-anatomical analysis. Clinical results of a surgical cohort are presented. Study Design: Cohort prospective study. Methods: Clinical data, including age, gender, stage, histopathological findings, rate of complications and appearance of PCF at fifth day and two months postoperative were recorded. Postoperative morbidities were recorded as wound abnormalities, nasosinusal, orbital and central nervous system complications. Chi-squared test was used to correlate qualitative variables and Student-t-test to correlated qualitative and quantitative variables. Items were considered statistically significant with a p value of less than 0.05 (confidence Interval of 95%). Results: Thirty patients (18 males and 12 females) were registered. Mean age was 51.5 years ± 23.0 and range between 20 and 71 years. Most common histologic subtypes were adenocarcinoma, epidermoid carcinoma and squamous cell carcinoma. Complete resection of the tumor was achieved in all patients including surgical margins. Length of the PCF varies between 9.9 cm and 13.9 cm with a mean of 11.8 cm. There was an association between length of the flaps and the covering structure with the nose apex relation. None patient experienced postoperative cerebrospinal fluid (CSF) leak, frontal sinusitis or other complications. Conclusions: Minimally invasive PCF constitute a good and inexpensive reconstructive option in patients with malignant anterior cranial base tumors in whose nasoseptal flap was not a feasible option.

A Novel Classification of Brain Invasion in Malignant Ethmoidal Tumors and Management Proposal

Object: Brain invasion is unusual in patients with paranasal sinuses cancer. Staging systems do not specify brain invasion extension who has an impact in therapeutic strategy and prognosis. Surgical series of this patient treated by endonasal endoscopic approach are scarce. In this paper, a novel classification and surgical strategy is proposed. Methods: A retrospective review of patients with ethmoidal malignant tumors with brain invasion treated at the National Institute of Oncology and Radiobiology from January 2015 to October 2017 by means endonasal endoscopic surgery was performed. All medical records were reviewed for demographics, diagnoses, presentation, endoscopic approach, reconstructive techniques and clinical outcomes. Pattern of brain invasion was classified in five grades. Chi-squared test, ANOVA test and Kaplan-Meier curves were used. Results: Forty-seven patients (26 males and 21 females) were registered. Mean age was 52.3 years ± 27.0. Only 3 patients presented with neurologic symptoms. Histologic subtypes were squamous cell carcinoma (25 patients), adenocarcinoma (16 patients), and esthesioneuroblastoma (6 patients). Five patients corresponded to Grade I, 39 Grade II and 3 Grade III. The mean surgical time was 351.9 min (±45). The mean blood loss was 704.5 ml (±206). The mean ICU stay was 1.1 (ranging from 1 to 2 ) days and the hospital stay was 5.3 (ranging from 5 to 7) days. Conclusions: Brain invasion represents a particular therapeutic challenge in patients with malignant nasosinusal tumors. Surgical treatment is possible in some cases, including endonasal endoscopic approach. A stage classification of brain invasion helps to establish an optimal surgical strategy and a prognosis.