Cerebrospinal fluid rhinorrhea repair through ethmoid 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 Otolaryngologists are more accustomed to repairing the cerebrospinal fluid rhinorrhea at the anterior cranial fossa through the external sinus approach. The sinus sinus approach for cerebrospinal fluid rhinorrhea repair can also be used to repair the cerebrospinal fluid rhinorrhea in the sellar region. 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. Infectious diseases of the nasal cavity and sinuses should be treated and treated with antibiotics. 3. Prepare blood. 4. Cut nose hair, shaving and eyebrows. Surgical procedure 1. Suture the upper and lower eyelids and cover the eyes with Vaseline gauze. 2. Incision: The upper edge of the eyelid of the nose is lifted from the upper edge of the eyelid and the lower end of the eyebrow. The arc-shaped incision is made along the nasal and buccal groove between the bridge of the nose and the medial malleolus. This incision is slightly longer than the nasal sinus surgery incision, but shorter than the nasal incision, and a transverse incision can be made in the nasal root if necessary. 3. Isolation: The incision was separated along the bone wall with a periosteal stripper to reveal the nasal bone, the maxillary frontal process, the lacrimal bone, the frontal bone nose and the sieline paper template and the upper edge of the pear-shaped hole. 4. Use the maxillary sinus bite tongs to bite off the anterior and posterior nasal bone wall through the pear-shaped hole, or use a bone knife or a flat chisel to open the nasal joint, nasal prosthesis and nasal foramen. It is reset at the end of the operation to avoid local deformities. 5. Expand the field: use a rongeur or a curette to remove part of the tear bone, remove the rib bone pattern and the sinus ventricle, and expose the frontal sinus floor and the nasal base of the skull to find the leak. If there is clear liquid from the frontal sinus Or the bottom of the skull, you should find out its source and find the leak. 6. Repair the leak: the nose leak in the frontal sinus should open the frontal sinus floor, scrape the sinus mucosa, fill the sinus cavity with fascia and muscle; in the skull base, the leak should be scraped and the mucosa around it. Causes fresh wounds, leaking muscles and fascia from the leaking hole, covering the fascia on the nasal side, and then transposition the middle turbinate or the posterior segment of the nasal septum to support and strengthen the fascia. Meninges or meninges-brain bulging should be reimbursed, those who can not be reconciled are ligated and resected at their roots, and the stump is still in the cranium and then filled with muscles and fascia. The nasal side is covered with fascia and skull base. Bone wall defects require repair, small defects can be used in the posterior segment of the nasal septum, large defects need to be repaired with the humerus. The repair method is to first put the beaten muscles and fascia at the leak hole, and then repair the defect with the bone plate. The bone plate should be placed on the cranial side of the skull base (the anterior cranial fossa) and ride across the defect, otherwise it is difficult to repair. It works. The nasal side of the repaired bone plate should be covered with a fascia. If the rhinorrhea is in the sellar region, first open the anterior wall of the sphenoid sinus, remove the sinus mucosa, repair the leak or fill the sinus cavity with muscle or fat. 7. Nasal filling: After repairing the leaking hole, put a layer of absorbable gelatin sponge on the surface of the implanted fascia; then press it with iodoform gauze, and the other end of the gauze is taken out from the front hole of the nose; Place a layer of absorbable gelatin sponge on the stuffed gauze. The nasal bone was repositioned and the incision was sutured layer by layer. 8. Dressing: The incision is placed in a sterile dressing, and the bandage is used to make a single eye bandage. complication 1. Olfactory loss Through the external ethmoid sinus surgery approach can damage the olfactory nerve or the structure of the olfactory area caused by 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. Frontal osteomyelitis wound infection or bone window with the same sinus and the sinus mucosa did not completely scrape the frontal bone infection, causing osteomyelitis.