Cerebrospinal fluid rhinorrhea repair via forehead 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. Treatment of diseases: traumatic cerebrospinal fluid leakage cerebrospinal fluid leakage Indication The cerebrospinal fluid rhinorrhea repair through the forehead approach is suitable for cerebrospinal fluid leakage in the frontal sinus, ethmoid sinus and other parts of the anterior cranial fossa. 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. Prepare blood. 3. Shave the hair, if you want to take the fascia, you must also prepare the skin in the corresponding area. 4. 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. Surgical procedure Incision According to the patient's condition, a bilateral sacral lateral incision or a median sagittal incision and a lateral forehead coronal incision may be made in the forehead hairline. The apical sagittal incision is connected to the inner end of the coronal incision and reaches the bone wall; if the forehead pedicle cap is to be used The sacral membrane and periosteum can be cut into the subcutaneous tissue, and the deep incision can be made into a linear or wavy shape, which is more in line with the cosmetic requirements. 2. Separation The incision deep into the bone wall can be separated along the bone wall to the eyebrow arch. The aponeurosis and periosteum grafts were taken from the superficial aponeurosis to the plane of the eyebrow arch, and then the aponeurosis and periosteum were cut in the middle, and the pedicle was in the plane of the eyebrow. The tissue was wide and narrow. The length is determined as needed. In order to ensure the blood supply of the pedicled tissue flap, the pedicle width is at least 2 cm. The forehead tissue is dominated by the branch of the internal artery of the internal carotid artery. The upper artery is about 2 cm from the midline. It is the upper artery of the trochlear artery. The upper iliac artery is about 2.5 cm from the midline. Be careful not to injure the two arteries when cutting the tissue flap for transplantation. The aponeurosis and periosteum on both sides of the tissue flap remain on the surface of the frontal bone. 3. Forehead open bone window The frontal bone window can be selected on one side or in the middle according to the situation. The size can be 3cm×4cm or 4cm×5cm. The upper and lower sides are slightly shorter, and the left and right sides are slightly wider. The electric drill is used to drill holes in the four corners to expose the dura mater. Separation between the cranial side of the frontal bone and the dura mater, the wire saw enters from one hole by the guide plate, the other hole is taken out, the four sides are sawn off, and the bone plate is taken out to reveal the frontal dura mater. The lower edge of the bone window can be close to the upper edge of the eyebrow, which is beneficial to the front of the cranial fossa. However, this often makes the well-developed frontal sinus open. In order to avoid opening the frontal sinus, some people open the bone window at a higher position above the frontal sinus. Such a bone window has a certain influence on the exposure of the anterior cranial fossa. If the frontal sinus is open, the sinus mucosa should be completely removed, and the frontal sinus opening and filling of the sinus cavity should be closed with fascia to avoid intracranial infection and frontal osteomyelitis. 4. Find and repair leaks There are two ways to find and repair leaks: one is to repair the epidural; the other is to cut the dura mater and repair it in the dura. The former is to separate the cranial anterior fossa outside the dura mater, and press the dura mater back slightly to reveal the anterior cranial fossa and find the leak. After seeing the leaky hole, the forehead pedicle tissue can be repaired. It can also be repaired by the free fascia taken from the forehead or the fascia from the outside of the thigh. The graft should be placed at the leak hole. There should be enough fascia behind the leak. . The dura mater should be sutured with the graft 1 or 2 as far as possible behind the leak to prevent the graft from shifting. If the skull base defect exceeds 1.0cm×0.5cm, it can be repaired by the frontal bone plate or the frontal cortical bone. Repair the skull base with the bone plate should be covered with fascia at the bone defect, close the passage between the nose and the skull to prevent infection, then release the bone plate, and then put the fascia on the bone plate, which is called "sandwich" method. . Cerebrospinal fluid rhinorrhea often lower intracranial pressure, such as higher intracranial pressure, affecting the extradural separation, dehydration agents or diuretics may be used. Extradural repair requires extensive drainage of the dura mater from the anterior cranial fossa, the cockscomb and the frit. This tends to damage both sides of the olfactory nerve and can increase the dural rupture when separated. However, because of the operation outside the epidural, no disturbance to the brain tissue, no new incision of the dura mater, and repair of the skull wall defect, the otolaryngologist prefers to use it. Intradural repair is to cut the dura mater, push the frontal lobe tissue backwards, reveal the anterior cranial fossa, and find leaks. After the leak was found, the fascia was placed between the dura mater and the arachnoid surface of the brain tissue, and the graft was sutured with the dura mater, and the meningeal incision was sutured. This method has a wide range of surgical exposure, such as suspected intracranial lesions can also be explored at the same time. Neurosurgeons prefer this method, but this method must cut the dura mater, cause new wounds, have some disturbance to the brain tissue, and inconvenient to repair the skull base defect. 5. Stitching and dressing wounds After repairing the leaky hole, the frontal bone plate is reset, and the periphery and the bone window can be drilled and fixed first, or directly restored. The four corner defects can be filled with broken bone or gelatin sponge, and the rubber drainage strip between the skin flap and the frontal bone. The skin incision was sutured layer by layer, and the wound was covered with a sterile dressing, and then bandaged with two bandages to suppress hemostasis. complication Olfactory loss The forehead approach can damage the olfactory nerve or the structure of the olfactory area to cause olfactory loss, and protect the contralateral olfactory nerve and olfactory area during surgery. 2. Suppurative meningitis It is common in cases where the sinus mucosa is not completely scraped and the graft is filled. The infection, liquefaction and necrosis of the graft cause intracranial infection. Therefore, the sinus mucosa must be completely removed when the sinus cavity is filled and repaired. 3. Frontal osteomyelitis The forehead wound infection or the bone window is connected to the same sinus and the sinus mucosa is not completely scraped to cause the frontal bone infection, causing osteomyelitis.