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Background  Numerous methods have been described to repair nasal cerebrospinal fluid (CSF) leaks. Most studies have focused on optimizing CSF leak repair success, leading to closure rates of 90 to 95%. Objective  This study aimed to determine if excellent reconstruction rates could be achieved without using sinonasal packing. Methods  A prospective case series of 73 consecutive patients with various CSF leak etiologies and skull base defects was conducted to evaluate reconstruction success without sinonasal packing. The primary outcome measure was postoperative CSF leak. Secondary outcome measures were postoperative epistaxis requiring intervention in operating room or emergency department, infectious sinusitis, and 22-item sinonasal outcome test (SNOT-22) changes. Results  Mean age was 54.5 years and 64% were female. Multilayered reconstructions were performed in 55.3% of cases, with collagen or bone epidural inlay grafts, and nasal mucosal grafts or nasoseptal flaps for onlay layers. Onlay-only reconstructions with mucosal grafts or nasoseptal flaps were performed in 44.7% of cases. Tissue sealants were used in all cases, and lumbar drains were used in 40.8% of cases. There were two initial failures (97.4% initial success), but both resolved with lumbar drains alone (no revision surgeries). There were no instances of postoperative epistaxis requiring intervention in the operating room or emergency department. Infectious sinusitis occurred in 2.7% of patients in the first 3 months postoperatively. SNOT-22 did not change significantly from preoperatively to first postoperative visits, then improved over time. Conclusion  Nasal CSF leaks from various etiologies and defect sites were successfully repaired without using sinonasal packing, and patients experienced minimal sinonasal morbidity., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objectives  Prolactinomas are the most common functional pituitary adenoma. Symptoms of a prolactinoma stem from hormonal causes (menstrual irregularities, galactorrhea, and reduced libido) or from tumor mass effect (visual changes and headache). Gender differences have been noted in prolactinomas, with males presenting with larger tumors and sequelae of mass effect, while females present commonly with hormonal symptoms. The purpose of this study is to evaluate differences in patient and disease characteristics, and outcomes between male and female prolactinoma patients undergoing surgery. Design  This was a retrospective chart review. Setting  This was done at the tertiary medical center. Participants  The medical records of prolactinomas patients who underwent endoscopic endonasal surgery between March 2008 and August 2016 were reviewed. Main Outcome Measures  Demographic information, tumor characteristics, and treatment characteristics and outcomes were collected. Statistical analysis was performed using chi-squared test or Student's t -test as applicable. Results  Seventy-nine patients were identified, 22 males and 57 females. The average age for males was 38 years and for females was 35 years. Males were more likely to present with decreased libido ( p  < 0.0001), whereas females more often presented with galactorrhea ( p  < 0.0001) and menstrual irregularities. Tumor size was larger in males ( p  = 0.0044) with higher likelihood of suprasellar extension ( p  = 0.0409) and cavernous sinus invasion ( p  = 0.0026). Males were more likely to have a subtotal resection rather than gross total resection ( p  = 0.0086) and less likely to have normalization of prolactin levels following surgery ( p  = 0.0019) Conclusion  Male prolactinoma patients tend to have larger tumors with more aggressive features. This may have a role in the differences in outcomes noted in this study.

Objectives/Hypotheses  To assess quality of life (QOL) after transnasal, endoscopic pituitary surgery using the 36-item short form (SF-36) instrument. Design  Retrospective review was used for this study. Setting  The study was conducted in a tertiary academic medical center. Participants  Patients who underwent endoscopic, transnasal, transsphenoidal surgery for pituitary adenomas between January 1, 2007 and July 1, 2016 and completed preoperative and postoperative SF-36 surveys. Main Outcome Measures  SF-36 survey data as measured by its eight domains (physical functioning, physical role functioning, emotional role functioning, energy/fatigue, emotional well-being, social functioning, pain, and general health). Results  There were 18 preoperative, 13 short-term (2 weeks or less after surgery) postoperative, and 14 longer term (>2 weeks after surgery) postoperative surveys. There was no significant difference between preoperative and long-term postoperative SF-36 scores across domains ( p  > 0.05). In comparing short-term postoperative and preoperative scores, tumor size was positively associated with emotional well-being ( p  = 0.049) and general health scores ( p  = 0.031), while visual changes preoperatively were positively associated with general health scores ( p  = 0.046). Compared with standard U.S. general population summary data, these patients scored lower preoperatively in all domains except for emotional role functioning and pain ( p  < 0.05). Postoperatively, patients improved to baseline general population data scores with the exception of the physical role functioning domain ( p  < 0.0001). Conclusion  Patients undergoing endoscopic, transnasal, transsphenoidal surgery for pituitary adenomas had lower QOL in six of eight domains preoperatively, but improved to baseline values on the long run after surgery in seven of eight domains. This suggests that minimally invasive pituitary surgery has a restorative role in general QOL as measured by the SF-36.

Objectives/Hypotheses  The endoscopic endonasal approach (EEA) is the workhorse endoscopic procedure for sellar and parasellar pathology. Various reconstruction techniques have been reported following EEA surgery, ranging from no reconstruction to vascularized flaps. We review our institution's experience with sellar reconstruction following EEA and propose an evidence-based algorithm. Design  Retrospective review. Setting  Tertiary academic medical center. Participants  Patients who underwent endoscopic EEA surgery for sellar or parasellar pathology between March 1, 2013 and August 31, 2016. Main Outcome Measures  Patient demographic and clinicopathologic data were collected. Outcome measures included intraoperative and postoperative cerebrospinal fluid (CSF) leak rates and extent of resection (gross or subtotal). Results  Three hundred consecutive patients were included. Depending on the presence and grade of intraoperative CSF leak, cases were reconstructed using either a free mucosal graft (FMG) or nasoseptal flap (NSF). Intraoperative and postoperative CSF leak rates were 30.7% and 2.3%, respectively. Multivariable logistic regression found that intraoperative CSF leak was associated with recurrent disease (odds ratio [OR] 2.47, p  = 0.004), with no apparent predictors of postoperative CSF leak. Conclusions  Based on this large series, we propose the following algorithm for sellar reconstruction: FMG for no CSF leak; fat graft + FMG ± rigid fixation for low-grade leaks; and fat graft + NSF ± rigid fixation for high-grade leaks.

Objectives  Rathke's cleft cysts (RCC) are benign cystic lesions of the sella resulting from incomplete obliteration of Rathke's cleft. Symptomatic lesions often require surgical decompression, which is often amenable to a transnasal, transsphenoidal (TNTS) approach. We report our experience with marsupialization of RCC and describe a novel technique to promote re-epithelization of the cyst cavity. Design  Retrospective review. Setting  Tertiary academic medical center. Participants  Patients who underwent TNTS for RCC between 2007 and 2015. Main Outcome Measures  Demographics, lesion characteristics, and reconstruction and treatment outcomes. Results  In total, 52 patients were identified. The mean age was 41 ± 18 years. The mean RCC size was 13 ± 5 mm. Intraoperative cerebrospinal fluid (CSF) leak was encountered in 14 (27%) patients; all were repaired. There were six complications (12%) and no deaths. Mean follow-up was 20 ± 18 months, with five (10%) recurrences. RCC size was associated with intraoperative CSF leak ( p  = 0.04). In 12 patients, the marsupialized cyst cavity was lined with a free mucosal graft (FMG) to promote healing and re-epithelialization. Conclusions  The TNTS approach is safe and effective in surgical decompression of RCC. Lining the exposed cyst cavity with an FMG is a simple intervention without added morbidity that may promote formation of an epithelialized tract. Level of Evidence  Not applicable.

Objectives/Hypotheses  Functioning pituitary adenomas may produce endocrinopathies such as acromegaly and Cushing syndrome. Both conditions lead to characteristic anatomic variations as a result of hormonally induced abnormal soft tissue deposition. We evaluate the anatomic differences between acromegalics and Cushing disease patients and compare these dimensions to controls. Design  Radiographic review of preoperative magnetic resonance images (MRI) of the pituitary gland. Setting  Tertiary academic medical center. Participants  Patients who underwent transnasal, transsphenoidal surgery for pituitary adenomas found to have acromegaly or pituitary Cushing between January 1, 2007 and September 1, 2015. A total of 15 patients with similar MRIs and no history of pituitary or sinonasal disease were selected as controls. Main Outcome Measures  Dimensions assessed were intercarotid distance; carotid canal width; piriform aperture width; distance from the piriform aperture to the anterior face of the sphenoid; sphenoid sinus height, width, and length; angle from anterior nasal spine to anteroinferior face of sphenoid sinus; choanal height; and nasal cavity height at the level of the vertical segment of the middle turbinate. Sphenoid sinus pneumatization patterns were recorded. Results  There were 30 acromegalics and 31 Cushing disease patients. When compared with controls, both acromegalics and Cushing disease patients had significantly wider piriform apertures and a longer distance from the piriform aperture to the anterior face of the sphenoid sinus ( p  < 0.05). Acromegalics had a significantly less acute angle (19 ± 3 degrees) from the anterior nasal spine to the sphenoid ( p  < 0.05). Cushing disease patients had significantly lower sphenoid sinus length and shorter nasal cavity height ( p  < 0.05). There were no differences in intercarotid distance or carotid canal width. Conclusions  As acromegalics and Cushing disease patients have known anatomic variations, the skull base surgeon should be aware of these differences and adapt their techniques and approaches as needed.

Objectives  Bilateral anterior skull base (ASB) defects following endoscopic endonasal tumor resection are most commonly repaired utilizing multilayered reconstruction with a vascularized mucosal flap. Single-layer closure of large ASB defects has been described in the literature but this technique has yet to gain a widespread use. We report our experience with a series of patients who underwent reconstruction of large ASB defects using a single-layer intradural graft, without nasoseptal flaps. We also compared the use of acellular dermal matrix (AlloDerm, LifeCell, Branchburg, New Jersey, United States) or collagen matrix xenograft (Duramatrix, Stryker, Kalamazoo, Michigan, United States) as the graft biomaterial. Design  A retrospective case series. Setting  Tertiary academic medical center. Main Outcome Measures  Postoperative cerebrospinal fluid leak, the number of postoperative debridements, the number of postoperative infections, and time to remucosalization. Results  Two patients were reconstructed with AlloDerm and three with Duramatrix, with all patients receiving postoperative external beam radiation. There were no postoperative cerebrospinal fluid leaks identified in these patients during follow-up. The AlloDerm group showed increased postsurgical crusting, the number of clinically apparent postoperative infections, and an increased time to remucosalization. Conclusions  Single-layer repair without a vascularized mucosal flap is a viable method of skull base repair for large ASB defects. We found repair with Duramatrix was superior, with less graft crusting and infection, requiring fewer debridements.

Objectives  The nasoseptal flap (NSF) has become the workhorse for reconstruction in endoscopic endonasal skull-base surgery. The NSF, though useful in reconstruction, may lead to significant donor site morbidity. Published techniques to reduce the donor site morbidity, free mucosal grafts, and septal rotational flaps have shown to reduce crusting and remucosalization times. We present a novel technique utilizing posterior septal mucosa as a free mucosal graft for reconstruction of the anterior septal donor site. The septal mucosal graft is taken from the mucosa overlying the posterior septectomy site of the endonasal approach to skull base tumors. Design  Retrospective chart review. Setting  Single tertiary academic medical center. Participants  All patients who underwent endoscopic endonasal skull-base surgery between November 1, 2014 and August 30, 2015 with free mucosal graft reconstruction of the NSF donor site. Main Outcome Measures  Postoperative graft success. Results  Fifteen patients underwent septal reconstruction using a septal free mucosal graft. There was a 100% graft success rate with near complete remucosalization by 6 weeks postoperatively. Conclusions  The posterior septal free mucosal graft is a simple, reliable method for reconstructing the NSF donor site. The advantages of this technique include utilization of native septal mucosal tissue and middle turbinate preservation.