[Diagnosis and treatment of frontobasal cerebrospinal fluid fistulas]

[Diagnosis and Treatment in frontobasal fractures]

Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.

Clinical Efficacy of the Multilayered Skull Base Reconstruction Using In Situ Bone Flap in Endoscopic Endonasal Approach for Craniopharyngioma

Objective  The aim of the study is to summarize and analyze the efficacy of the multilayered skull base reconstruction using in situ bone flap in endoscopic endonasal approach (EEA) for craniopharyngiomas. Methods  A retrospective review of 65 patients who underwent resection of their histopathology confirmed craniopharyngiomas performed at a single institution. Based on the team's understanding and mastery of skull base reconstruction techniques, patients were divided into two groups according to the methods of reconstruction in two periods. First (March 2015 through August 2016), osseous reconstruction was not adopted and served as the control group (34 cases). Second (September 2016 through July 2019), in situ bone flap repair of the skull base (complete osseous reconstruction) served as observation group (31 cases). The length of hospitalization and nasal exudation, bed rest time of hospital discharge, the incidence of cerebrospinal fluid leaks, lumbar drainage, and intracranial/pulmonary infections were collected and compared. Results  Compared with the control group, patients in the observation group had obviously less lumbar drainage and CSF leakage ( p  < 0.05), but had no significant difference in cases of re-operation, meningitis, and pulmonary infection. At the meantime, cases of nasal exudation, bed rest, and hospitalization of the observation group were significantly reduced ( p  < 0.05) in the observation group. Conclusion  The multilayered reconstruction technique (especially using in situ bone flap, combined with vascularized pedicled nasoseptal flap) is a safe and effective method in achieving watertight closure after EEEA, and can significantly reduce the incidence of cerebrospinal fluid leaks, and facilitate rehabilitation in skull base reconstruction of craniopharyngiomas.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Skull base injury with extensive pneumocephalus after transnasal endotracheal intubation

Iatrogenic injuries of the frontal skull base commonly occur during endoscopic sinus surgery. In this paper, we present a rare case of cranial base injury after transnasal endotracheal intubation for dental surgery. A 61-year-old otherwise healthy man presented at the emergency department with headache, right leg weakness and watery nasal discharge on the left side. He underwent a dental surgery under general anaesthesia with transnasal endotracheal intubation 2 days earlier. A CT of the head showed a bone defect of the left skull base with a bifrontal pneumocephalus. Urgent endoscopic sinus surgery with exposure of the skull base was performed. The anterior part of the middle nasal turbinate was found dislocated and resulted in an injury of the lateral lamella of the cribriform plate. After endoscopic reconstruction of the bone defect, the patient showed a rapid improvement of symptoms. Two years after surgery the patient is free of symptoms.

Surgery of the ear and the lateral skull base: pitfalls and complications

Surgery of the ear and the lateral skull base is a fascinating, yet challenging field in otorhinolaryngology. A thorough knowledge of the associated complications and pitfalls is indispensable for the surgeon, not only to provide the best possible care to his patients, but also to further improve his surgical skills. Following a summary about general aspects in pre-, intra-and postoperative care of patients with disorders of the ear/lateral skull base, this article covers the most common pitfalls and complications in stapes surgery, cochlear implantation and surgery of vestibular schwannomas and jugulotympanal paragangliomas. Based on these exemplary procedures, basic "dos and don'ts" of skull base surgery are explained, which the reader can easily transfer to other disorders. Special emphasis is laid on functional aspects, such as hearing, balance and facial nerve function. Furthermore, the topics of infection, bleeding, skull base defects, quality of life and indication for revision surgery are discussed. An open communication about complications and pitfalls in ear/lateral skull base surgery among surgeons is a prerequisite for the further advancement of this fascinating field in ENT surgery. This article is meant to be a contribution to this process.