Cerebrospinal fluid rhinorrhea repair via oral-nasal-sphenoid approach

Cerebrospinal fluid rhinorrhea is a disease caused by meningeal rupture, cerebrospinal fluid from the sinus or nasal cavity of the skull into the sinus or nasal cavity, overflowing from the anterior or nasopharynx, often accompanied by purulent meningitis and life-threatening. Surgical repair is an effective treatment. Before the operation, the leaking fluid must be carefully analyzed to determine whether it is cerebrospinal fluid, and the location of the leak is determined by examination of symptoms, signs, and necessary images or isotopes. First, the cerebrospinal fluid otorrhea should be excluded, that is, the cerebrospinal fluid flows through the middle ear and the eustachian tube to the nasopharynx and nasal cavity. Surgery repair methods mainly include the forehead approach, transnasal ethmoid sinus approach, oral-nasal-sphenoidal approach and cranial-nasal approach, which can be used according to different situations. The principles of cerebrospinal fluid rhinorrhea are as follows: 1 The cerebrospinal fluid rhinorrhea that occurs early after trauma is not considered for surgical repair, because many patients can heal themselves; 2 the disease is severe or there is obvious purulent meningitis, should be relieved, meningitis After being controlled, the operation is performed; 3 there is a primary disease, such as a cerebrospinal fluid rhinorrhea caused by tumor, meninges, brain swelling, etc., and nasal leakage should be repaired after the primary disease is treated or at the same time. Treating diseases: cerebrospinal fluid rhinorrhea Indication Oral-nasal-sphenoid sinus approach for cerebrospinal fluid rhinorrhea repair is suitable for nasal cerebrospinal fluid rhinorrhea repair only in the sella region, such as rhinorrhea after pituitary surgery. Preoperative preparation 1. Preoperative systemic examination, including liver and kidney function, cardiopulmonary condition and positive or lateral X-ray of the skull, CT scan of the head, etc., to understand the frontal sinus and skull base; biochemical examination of nasal leakage. 2. Preoperative antibiotics, and according to the requirements of general anesthesia to do the necessary preparation and medication, such as preoperative indwelling catheter, atropine sulfate intramuscular injection. 3. Oral and nasal and sinus inflammatory lesions should be treated accordingly, oral care before surgery, with antibiotics. 4. Prepare blood. 5. Cut the nose hair, shave the beard, take the fascia and prepare the skin at the muscles. Surgical procedure 1. The incision makes a transverse incision in the intercondylar sulcus, reaching the bone surface. 2. Separation In order to facilitate the separation of the septal mucosa of the nasal septum, 0.5% procaine can be used for submucosal infiltration of both sides of the nasal septum. The periosteal stripper was used to separate the distal end of the nasal septum and the piriform margins on both sides, and then the nasal mucosa was separated by the nasal septum stripper, and the periosteum was separated to the piriform hole, and the nasal septum was also separated. , separating backwards and upwards, revealing the vomer, the vertical plate of the ethmoid and the sphenoid bone mouth (pterin). 3. Cut the nasal septal cartilage and cut the nasal septal cartilage from front to back. Insert the long nose into the ipsilateral mucochondral membrane and the nasal septal cartilage, push the ipsilateral mucosal perichondrum to the lateral side, push the nasal septal cartilage to the opposite side, and enlarge the mucous cartilage. Membrane sac, exposed vomer, ethmoid vertical plate and sphenoid bone mouth. 4. Excision of the upper part of the vomer and the lower part of the vertical plate of the ethmoid and the sphenoid bone mouth, exposing the anterior and posterior wall of the sphenoid sinus. The electric drill opens its anterior wall and is enlarged with a sphenoidal squeezing forceps, including the anterior wall of the contralateral sphenoid sinus. 5. Excision of the sphenoid sinus septum, clearing the anterior wall of the sinus mucosa sphenoid sinus, the septum is removed, and the sinus mucosa is completely separated and removed, and the saddle bottom is revealed to find the leak. 6. Repair the leaky sinus cavity after the mucosa is completely removed, fill the sinus cavity with broken muscles and fascia. If necessary, take the bone piece and place it on both sides of the anterior wall of the sphenoid sinus or up and down to support the muscle implanted in the sinus cavity. , fat or fascia, to achieve the purpose of repairing leaks, the nasal cavity is filled with iodoform gauze. complication 1. Olfactory loss surgery can damage the olfactory nerve or the structure of the olfactory area to cause olfactory loss, and pay attention to protect the contralateral olfactory nerve and olfactory area during surgery. 2. Suppurative meningitis is common in cases where the sinus mucosa is not completely scraped and the graft is filled. The infection, liquefaction and necrosis cause intracranial infection. Therefore, the sinus mucosa must be completely removed when the sinus cavity is filled and repaired. . 3. Nasal septum perforation.