Variations of mucosal-sparing septectomy for endonasal approach to the craniocervical junction.
OBJECTIVES/HYPOTHESIS
Recent advances in surgical techniques have rendered the craniocervical junction (CCJ) accessible transnasally. Endoscopic endonasal transclival and transodontoid approaches are routinely performed in leading skull base centers. Usually, these approaches involve a posterior bony and mucosal septectomy, which may compromise the vascularized pedicled nasoseptal flap (PNSF), a robust reconstructive option for repair of large skull base defects. With the possibility of an intraoperative cerebrospinal fluid leak and the reported success of the PNSF for repair of these defects, preserving the integrity of the PNSF is beneficial during the endoscopic endonasal approach to the CCJ. We describe three new variations/refinements of the endoscopic endonasal approach to the CCJ that preserve the mucosal integrity of the posterior nasal septum and PNSF.


METHODS
Photo and video documentation of cadaveric dissections.


RESULTS
The steps required for the different variations in approaching the CCJ are demonstrated. These three options are: 1) nonopposing Killian incisions with submucosal elevation of PNSFs laterally under the inferior turbinates (the PNSFs are retracted laterally and left attached superiorly onto the nasal septum and laterally under the inferior turbinate); 2) bilateral non-opposing PNSFs tucked beneath their respective middle turbinate or into the sphenoid sinus; and 3) a hybrid approach combining option 1 performed on one side and option 2 on the contralateral side. All three options allowed for a mucosal-sparing septectomy to provide ample access to the CCJ.


CONCLUSION
These variations/refinements of the mucosal-sparing approach to the CCJ allowed adequate surgical access with sufficient maneuverability while preserving both PNSFs.


LEVEL OF EVIDENCE
NA. Laryngoscope, 126:2220-2225, 2016.
['Eloy|Jean Anderson|JA|', 'Vazquez|Alejandro|A|', 'Marchiano|Emily|E|', 'Baredes|Soly|S|', 'Liu|James K|JK|']
D002102:Cadaver D004210:Dissection D006801:Humans D009297:Nasal Mucosa D009300:Nasal Septum D057605:Natural Orifice Endoscopic Surgery D009666:Nose D059351:Organ Sparing Treatments D019651:Reconstructive Surgical Procedures D019291:Skull Base D013524:Surgical Flaps D014420:Turbinates
Craniocervical junction skull base nasoseptal flap endoscopic endonasal transclival approach endoscopic endonasal transodontoid approach endoscopic skull base surgery posterior septectomy rheumatoid pannus skull base approach skull base surgery