Redefining Care: Endoscopic Skull Base Surgery and Beyond (Podcast)

Several techniques and surgical approaches are improving success rates and minimizing morbidities in endoscopic skull base surgeries. In a recent Head & Neck Innovations podcast episode, Raj Sindwani, MD, Vice Chairman of Cleveland Clinic's Department of Otolaryngology-Head and Neck Surgery shares insights on some of these developments, his related research and the post-operative monitoring that is part of Cleveland Clinic's plan of care.

“We have evolved in our approach to the skull base, both routine pituitary surgery and really anything that's within this sphenoid proper,” says Dr. Sindwani. “Unlike many centers, we do not do formal ethmoidectomies on both sides, and we do not routinely take the middle turbinate either. There are a few reasons for that. One, we make very small openings in the back of the nose so that we can access through this sphenoid interior and the middle turbinate, we feel now that we've evolved in our facility with these techniques, isn't necessary to be removed...another reason is that it actually can serve as the guardian to a skull-based defect.”

In addition, they also discuss:

• Research insights on unplanned reoperations in skull-base surgery
• Collaborative efforts with Cleveland Clinic neurosurgeons
• Managing lateral sphenoid sinus meningoencephalocele
• Using fascia lata in complex reconstruction surgeries
• A first-of-its-kind educational opportunity coming up in the fall of 2024

Click the podcast player above to listen to the episode now, or read on for a short, edited excerpt. Check out more Head and Neck Innovations episodes at clevelandclinic.org/podcasts/head-and-neck-innovations or wherever you get your podcasts.

Excerpt from the podcast

Podcast host Paul Bryson, MD, MBA: You’ve talked about all the different windows and portals and reconstructing them and things like that. I also wanted to give a little time for you to talk about the evolution fascia reconstruction. You mentioned the workhorse nasal septal flaps, but if I recall, I understand that fascia lata is also a reconstructive ladder option for you in some of these complex skull-based defects. Can you give us an update on that?

Raj Sindwani: Sure, absolutely. You're right. So, while the nasal septal flap is the workhorse for pedicled reconstruction, and we use that for large complex tumor defects that often have high flow leaks to them, what you do as the first layer in these multi-layer reconstructions has been shown to be very important. So, we really have turned to fascia lata in our expanded, more complex, large defects — complex aggressive pathologies like craniopharyngioma, sometimes meningioma or other tumors. What we've found, and this was a large series that we presented a little while ago that's now been published in 2023, is that when we looked at this large series of consecutive expanded approach surgeries for the reasons I mentioned, when we use fascia, we had a higher than 92% success rate. And what we've learned from that is that the fascia really is something special.

We harvest fascia from the upper thigh through a small incision, and it's the iliotibial band that we're effectively taking. And so, we've been using it in a variety of different forms, which has also been a great learning experience.

The button graft was popularized some years ago. The idea here, Paul, is if you think about it, you make a big hole, and if there's a big tumor cavity that's now just open space, how do you make your inner layer stay at the level of the skull-based defect? It's going to float away if you just put a free graft. The idea of the button is you put two leaflets, one goes intradural sutured to an onlay leaflet of fascia or synthetic material, which stays on the level of the bone.

We've become so confident and comfortable using fascia lata that in our series, we actually have been using it most commonly as the button geometry that I described, but also in about 26% as a free graft monolayer, either inside as an intradural play or onlay. So, effectively, what we've now evolved to doing is using fascia one to augment the nasal septal flap, or indeed, in rare cases, to replace a pedicle nasal septal flap even in complex defects. The other thing the fascia allows us to do, and this is great for skull-base teams that maybe aren't as experienced, is that sometimes when you take out a big tumor, you end up with a very deep defect.

What we have been doing with the fascia and fat is I’ll parachute in a big swath of fascia, put some fat into the parachute, which effectively shortens the depth of my defect so that now my regular size, call it nasal septal flap will fit on top just fine. So, it's a nice trick to have in your back pocket for a few of these scenarios I'm talking about. And we've really now come to use it as our go-to for very complex, unusual defects.

Dr. Bryson: Well, it is very creative. And what has your observation been with sort of the patient experience? It's not too hard for the team to harvest. Maybe it saves them not the morbidity, but the experience of having the nasal septal flap. What's been your experience with how the patients recover and their general sense?

Dr. Sindwani: We do make it through a small incision. It is an open incision, and obviously through transnasal procedures, we rarely have to make incisions on the body and harvesting that tibial band does not really have much sequelae. We may think twice if it's a young, healthy person because there are reports of muscle herniation through that missing fascial band. But for most of our population, that's not really a consideration.

In that series that we published last year of 50 or so patients, there's only one donor site issue, which was a seroma, and it was managed conservatively — you aspirate it, put a pressure dressing on and that's about it. Once or twice over the past five years or so, we've passed on it because I can think of a really robust athletic hockey player that had aspirations of going to the NHL and things like that where we thought, maybe in this case, we'll turn to something else.