transfrontal approach

Treating diseases: cerebrospinal fluid rhinorrhea Indication 1. The ethmoid sinus tumor invades the anterior skull base, the anterior cranial fossa and its contents (meninges, brain tissue), such as olfactory neuroblastoma, squamous cell carcinoma. 2. Frontal sinus tumor destruction The frontal sinus plate invades the brain, involving the meninges, brain tissue and skull base. 3. Forehead, sputum meninges - brain swelling. 4. The skull base is traumatic and fractured. 5. Forehead, sieve cerebrospinal fluid rhinorrhea. 6. Amount, ethmoid osteoarthritis, osteomyelitis, necrosis of the anterior skull base, and abscess formation. Contraindications 1. The lesion extends down to the upper edge of the middle turbinate and the cranio-nasal approach is required. 2. Patients with lesions involving the orbit and sputum should undergo combined orbital surgery. 3. Patients with external nasal soft tissue can not undergo single-stroke surgery. Preoperative preparation The same as the amount of cerebrospinal fluid rhinorrhea repair. Systemic and local examinations related to the primary disease should also be performed, including imaging biopsy. Surgical procedure Incision According to the need, it is feasible to have a bilateral incision in the forehead hairline or a coronal incision on one side (lesion side). When the midline is perpendicular to the midline, the incision can be linear, or it can be wavy and deep. If you need to repair the skull base and meningeal defect with a pedicled aponeurotic periosteum flap, you can cut to the superficial aponeurosis, and then cut the flap to the bone surface. 2. Separation Retaining the pedicled aponeurosis and periosteal flaps first separate the flaps along the superficial plane to the plane of the eyebrow arch, and then separate the cap-like aponeurosis, periosteal flap, cap-shaped aponeurosis and periosteal flap along the bone surface. size. 3. Open bone window If there is no lesion in the frontal bone, the bone window can be opened according to the amount of cerebrospinal fluid rhinorrhea repair method; if there is frontal bone destruction, the diseased bone should be removed together. 4. Exposure of the dura mater and anterior skull base When opening the bone window, quickly input 20% mannitol 250 ml to reduce intracranial pressure, and separate between the inner side of the skull and the dura mater. If necessary, the separation range can reach the outer side of the dome and reach the visual cross. 5. Lesion removal First remove the skull base and intranasal lesions, and then remove the meninges and brain tissue lesions. After the brain tissue lesions are removed, the lesions are filled with gelatin sponge. Do not leave the dead space to avoid bleeding. When the anterior segment of the superior sagittal sinus and the cerebral palsy are involved, it should also At the same time, the upper sagittal sinus stump should be sutured to prevent bleeding. 6. Skull and dural repair Repair the bones of the skull base with the cortical bone layer, or remove the removed frontal bone, use one of them; if the forehead is involved, it can also be placed after cooking (boiling for half an hour); for dural defects The pedicled fascia flap or free fascia is repaired, placed under the dura mater, the edges are partially overlapped, and the continuous carpet is sutured. Repair the dural defect and rebuild the skull base. After meningeal repair, the irritated cavity, nasal iodoform gauze packing, the skull base defect should be repaired more than 1.0cm, in order to prevent meningeal bulging, the fascia should be used to cover the skull base defect to close the nose before bone repair The inner passage can be placed in the defect with a pedicled aponeurosis or free fascia, and then the bone plate is placed. 7. Suture incision After the frontal bone was restored, the incision was sutured in a full-thickness suture, and the rubber drainage strip was placed under the flap and the pressure was bandaged. complication Intracranial bleeding After the brain tissue lesions are removed, the dead space is not filled with gelatin sponge, which can cause hemorrhage. The anterior segment of the superior sagittal sinus is not firmly sutured, resulting in epidural or subdural and skull hematoma or hemorrhage. 2. Cerebrospinal fluid leakage and intracranial infection Postoperative cerebrospinal fluid leakage can occur after dural repair with non-healing; intracranial infections include meningitis, subdural abscess, and brain abscess. 3. Frontal osteomyelitis May cause infection or even cause osteonecrosis. 4. Olfactory loss Separation of the anterior cranial fossa damage olfactory nerve or resection of the lesion at the sieve plate to damage the olfactory nerve or due to the relationship between the lesion needs to remove the olfactory bulb and the local dura mater and the olfactory nerve.