Abstract
Background
Defects through the skull base into the paranasal sinuses can occur during anterior skull base procedures, risking cerebrospinal fluid leak and infection if not repaired.
Methods
We describe a muscle plug napkin ring technique for closure of small skull base defects, wherein a free muscle graft slightly bigger than the defect is packed tightly in the defect, half extracranially and half intracranially and sealed with fibrin glue. The technique is illustrated in the case of a 58-year-old woman with a large left medial sphenoid wing/clinoidal meningioma.
Conclusions
The muscle plug napkin ring technique is a simple solution to small skull base defects.
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Code availability
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Abbreviations
- ACP:
-
Anterior clinoid process
- CSF:
-
Cerebrospinal fluid
- CT:
-
Computed tomography
- ICA:
-
Internal carotid artery
- MCA:
-
Middle cerebral artery
- V2:
-
Second division of the trigeminal nerve
- V3:
-
Third division of the trigeminal nerve
References
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Acknowledgements
We thank Kristin Kraus for editorial assistance.
Author information
Authors and Affiliations
Contributions
Walid K. Salah: methodology, writing—original draft, visualization. Robert C. Rennert: methodology, writing—original draft, visualization. Vance Mortimer: resources, project administration, video construction. William T. Couldwell: conceptualization, resources, supervision, project administration, writing—review and editing. All authors read and approved the final manuscript.
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Ethics declarations
Ethics approval
Approval from the institutional review board is waived for case reports. All procedures performed in studies involving human participants were in accordance with the ethical standards of the (place name of institution and/or national research committee) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Consent to participate
The patient consented to participate.
Consent for publication
The patient consented to the publication of the case in this paper.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Additional information
Key Points
• Unrepaired skull base defects risk CSF leak and infection.
• Large defects can require local or free vascularized flaps.
• Small defects can be closed with the muscle plug napkin ring technique.
• Temporalis muscle is harvested and cut slightly bigger than the defect.
• Muscle is placed through the defect, half in the sinus and half intracranially.
• Fibrin glue is used to seal the muscle in place.
• Lumbar CSF release can buttress the repair.
• Defects in the paraclinoid, optic canal, anteromedial/anterolateral triangle, and frontal sinus regions are effectively managed.
• Preoperative imaging can identify high-risk anatomy for skull base breaches.
• Superolateral extension of the frontal sinus and pneumatization of the ACP increase risk for breaches.
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Salah, W.K., Rennert, R.C., Mortimer, V. et al. Closure of small skull base defects with muscle plug napkin ring technique: how I do it. Acta Neurochir 165, 2321–2325 (2023). https://doi.org/10.1007/s00701-023-05631-5
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DOI: https://doi.org/10.1007/s00701-023-05631-5