Rhinobasisdefekt – was tun? Fallserie und Algorithmus

 

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Zusammenfassung

Hintergrund: Die nach Tumorchirurgie oder Trauma eröffnete Rhinobasis bedarf einer suffi­zienten Versiegelung um Rhinoliquorrhoe, aszendierende Infek­tion und Hirngewebeprolaps zu verhindern. Frische und kleine Defekte können in der Regel problemlos durch das alleinige Einbringen von avitalem autologen (z. B. Muskel, Fett), allo- oder xenogenen sowie alloplastischen Material verschlossen werden. Bei größeren Defekten und bei Rezidiven ist diese Maßnahme oft unzureichend und verlangt nach zuverlässiger Versorgung der Rhinobasis mithilfe eines vaskularisierten lokalen oder distalen Gewebetransfers.

Material und Methode: Die vorliegende Fallserie stellt eine Stufentherapie zur Rhinobasisrekonstruktion vor, wobei der Schwerpunkt auf die interdisziplinäre Versorgung komplexer Defekte (Ausdehnung, Rezidive, Zustand nach Bestrahlung) mithilfe von vaskularisiertem Gewebetransfer gelegt wird.

Die im Rahmen der erweiterten endonasalen Schädelbasischirurgie entstandenen Defekte ließen sich durch lokale gefäßgestielte Schleimhautlappen aus dem Septum oder der unteren Muschel verschließen (n=31). Bei ausgedehnten Defekten, bspw. nach kombiniert transcranieller und endonasaler Vorgehensweise, war der suffiziente Verschluss durch Verwendung eines Galea-Periost-Lappens in der „Sandwich Technik“ mit Integration eines Calvarian Splits (n=10) möglich. Bei weiter lateral gelegenen frontobasalen Defekten gewährleistete der temporoparietale Muskel-Faszienlappen im „Onlay Verfahren“ auf der mit Faszia lata rekonstruierten Dura einen adäquaten Abschluss (n=4). Die Ultima ratio stellte die Versorgung der zu rekonstruierenden Rhinobasis mithilfe eines gefäßanastomisierten und desepithelisiertem Unterarmlappens dar (n=4).

Schlussfolgerung: In der Zusammenschau lassen sich komplexe Rhinobasisdefekte durch ein interdisziplinär abgestimmtes Konzept unter Integration des gesamten plastisch-rekonstruktiven Repertoires mit unterschiedlichen Materialen sowie lokalem und distalen vaskularisierten Gewebetransfer ­sicher verschließen.

Abstract

Background: After tumor surgery or traumatic defects the anterior skull base needs sufficient closure in order to prevent rhinoliquorrhea, ascending infection and brain tissue prolaps. Small defects are sufficiently closed by non-vital tissue, e. g. mucosa, muscle, fat, fascia, bone, allogenic, xenogenic or alloplastic material. Larger defects of the skull base often require more extensive surgery, including transfer of local or distal vascularized flaps. The current article presents a stepwise tutorial for reconstruction of the skull base and by a large case series focuses on the interdisciplinary therapy of complex (size, recurrence, after radiotherapy) skull base defects.

Material and Method: Complex defects with small diameter, which can occur after extended sinus surgery, were permanently closed by local mucosa flaps of the lower turbinate or of the septum (n=31). Larger defects, e. g. after combined transcranial and endonasal tumor surgery, were closed by a ‘sandwich technique’ containing a galea periost flap and a calvarian split transfer (n=10). Reconstruction of the dura with fascia lata and local transfer of the temporal muscle were efficient for frontobasal defects with a more lateral location (n=4). Transfer of a distal desepithelialised vascularized forearm flap represents the ultimate procedure for reconstruction of large skull base defects, which was performed in 4 of our patients.

Conclusion: Successive escalation of the therapy and integra­tion of the entire repertoire of plastic-reconstructive surgery allows for durable closure of complex skull base defects. In every case, close cooperation between ENT- and neurosurgeons is necessary for planning and performance of a successful surgical procedure.

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