Correction of the frontoethmoidal encephalomeningocele with minimal facial incision: modified Chula technique

Management of cerebrospinal-fluid-related intracranial abnormalities in frontoethmoidal encephalocele using "Shunt algorithm for frontoethmoidal encephalocele" (SAFE)

A cerebrospinal-fluid-related (CSF-related) problem occurred in 25-30% of frontoethmoidal encephalocele (FEE) cases. Since there was no algorithm or guideline, the judgment to treat the CSF-related problem often relies upon the surgeon's experience. In our institution, the early shunt was preferable to treat the problem, but it added risks to the children. We developed an algorithm, "Shunt Algorithm for Frontoethmoidal Encephalocele" (SAFE), to guide the surgeon in making the most reasonable decision. To evaluate the SAFE's efficacy in reducing unnecessary early shunting for FEE with CSF-related intracranial abnormality. Medical records of FEE patients with CSF-related abnormalities treated from January 2007 to December 2019 were reviewed. The patients were divided into two groups: before the SAFE group as group 1 (2007 - 2011) and after the SAFE group as group 2 (2012 - 2019). We excluded FEE patients without CSF-related abnormalities. We compared the number of shunts and the complications between the two groups. One hundred and twenty-nine patient's medical records were reviewed. The males were predominating (79 versus 50 patients) with an average age of 58.2±7.1 months old (6 to 276 months old). Ventriculomegaly was found in 18 cases, arachnoid cysts in 46 cases, porencephalic cysts in 19 cases, and ventricular malformation in 46 cases. Group 1, with a score of 4 to 7 (19 cases), received an early shunt along with the FEE repair. Complications occurred in 7 patients of this group. Group 2, with a score of 4-7, received shunts only after the complication occurred in 3 cases (pseudomeningocele unresponsive with conservative treatment and re-operation in 2 cases; a sign of intracranial hypertension in 1 case). No complication occurred in this group. Groups 1 and 2, with scores of 8 or higher (6 and 8 cases, respectively), underwent direct shunt, with one complication (exposed shunt) in each group. The SAFE decision algorithm for FEE with CSF-related intracranial abnormalities has proven effective in reducing unnecessary shunting and the rate of shunt complications.

Immediate Resection and Reconstruction of Encephalocele in the Craniofacial Region

INTRODUCTION

Congenital meningoencephalocele is a herniation of brain and meninges through a skull base defect. It may result not only in neural defects, sensorimotor deficits, neurological morbidities, visual impairment, impaired nasal function, and a potential risk of intracranial infection. Goals of surgery include removal or repositioning of nonfunctional cerebral tissue, closure of the dura, and reconstruction of skeletal and cutaneous structures.

MATERIALS AND METHODS

The authors present the case of a 4-months-old infant who was found to have a frontoethmoidal encephalomeningocele that was only discovered after birth, the volume increased gradually. After multiple department discussions, the procedures were planned in 2-staged surgical protocol comprising of the first stage urgently performed by neurosurgeon and craniomaxillofacial surgeon, which aimed at removal or repositioning of nonfunctional cerebral tissue, closure of the dura, and reconstruction of skeletal; then second stage was performed by plastic surgeon to correct craniofacial hard and soft tissue deformities.

RESULTS AND CONCLUSIONS

The surgical procedures for frontoethmoidal encephalomeningocele are complicated, particularly for the infant. In order to achieve the final surgical purpose, it needs multiple department cooperation to make the surgical plans.

The extracranial versus intracranial approach In frontoethmoidal encephalocele corrective surgery: a meta-analysis

The debate between the extracranial and the intracranial approach for frontoethmoidal (FEE) encephalocele corrective surgery was not summarized yet. The extracranial approach is traditionally believed being inferior to the intracranial approach, but convincing evidence was missing. To provide robust evidence, we conducted a meta-analysis on the incidence of cerebrospinal fluid (CSF) leakage, its progression to infection, the reoperation to treat the leakage, and the recurrence rate between the two techniques. We performed a meta-proportion pooled analysis and meta-analysis on eligible literature following the recommendation of PRISMA guidelines. The outcome of interest was the incidence of CSF leakage, the CSF leakage that progressed into an infection, the reoperation rate to treat the leakage, and the recurrence rate. We included 28 studies comprising 1793 patients in the pooled prevalence calculations. Of the 28 studies, nine studies describing 730 patients were eligible for meta-analysis. The prevalence of CSF leakage was 8% (95% CI, 0.04-0.12) in the intracranial approach and 10% (95% CI, 0.01-0.23) in the extracranial approach The subgroup analysis of the intracranial approach showed higher CSF leakage prevalence in the frontal craniotomy approach (9%; 95% CI, 0.03-0.16) than the subfrontal osteotomy (6%; 95% CI, 0.03-0.12). Meta-analysis study revealed a significantly higher risk of CSF leakage (OR 2.82; 95% CI, 1.03-7.72), a higher reoperation rate (OR 5.38; 95% CI: 1.13 - 25.76), and the recurrence rate (RR 4.63; 95% CI, 1.51-14.20) for the extracranial approach. The event of infected CSF leakage (OR 3.69; 95% CI, 0.52-26.37) was higher in the extracranial than intracranial approach without any statistical significance. The extracranial approach was associated with a higher risk of CSF leakage, reoperation rate to treat the CSF leakage, and the recurrence rates. The infected CSF leakage between the extracranial and intracranial approaches showed no significant difference.

Treating nasoethmoidal encephalocele in a low-resource country: a surgical experience from a Philippine multidisciplinary craniofacial team

PURPOSE

It was described that nasoethmoidal encephalocele repair in the Philippines has been limited by insufficient resources, financial constraints, and a lack of surgical expertise. The purpose of this study was to report initial results and complications of Philippine patients with nasoethmoidal encephalocele surgically managed with an approach adapted to an environment with limited financial resources.

METHODS

All patients (n = 21) with nasoethmoidal encephalocele who underwent intracranial and extracranial repairs (frontal wedge osteotomy to access the encephalocele cyst and cranial base defect, dural defect repair, split frontal grafts fixed with polydioxanone sutures to reconstruct the cranial defect and nasal dorsum, and medial canthopexy) from January 2015 to May 2017 were included. The correlations between sizes of masses and cranial defects with the occurrence of complications were tested. The surgical results were classified based on a previously published outcome grading scales I-IV on the need for additional surgery.

RESULTS

Nineteen patients (90.5%) had unremarkable post-operative course. Two patients (9.5%) presented with complications (cerebrospinal fluid leak and surgical site infection) which were successfully managed with no additional surgery. The sizes of masses and cranial defects were not correlated (p > 0.05) with complications. The overall rate of surgical results ranked according to the need for additional surgery was 2.4 ± 0.5 (between categories II and III).

CONCLUSIONS

We reported successful surgical repair of nasoethmoidal encephaloceles in Philippine patients by a local multidisciplinary craniofacial team.

Frontoethmoidal encephalocele: clinical presentation, diagnosis, treatment, and complications in 400 cases

PURPOSE

The purpose of this study is to review a large series of frontoethmoidal encephalocele (FEE) regarding their clinical presentation, the progressiveness of the mass volume, the skin stigmata as well as its surgical approach and post-surgical complications.

METHOD

Records of all FEE patients treated in Soetomo General Hospital, Surabaya, and Charity Foundation Program from 2008 to 2015 were reviewed. Detailed patient's demography, clinical findings, radiology results, operative procedures, and complications were documented. Follow-up was organized in weekly basis for the first 1 month after surgery or more often when situation or complication occurred. Wound healing, neurological assessment for new or progressive deficit, pseudomeningocele, skin breakdown, cerebrospinal fluid (CSF) leakage, exposed implant, recurrent mass, and cosmetic results were documented. Since most of the patients had no direct phone line at their hometown, we relied on social worker to contact them.

RESULTS

One-stage surgery was performed for 400 patients with FEE (212 were male and 188 were female). Of 400 patients, 388 (97%) were younger than 18 years old. Most FEEs were nasoethmoidal, either isolated or combined with nasoorbital type (347 cases [86.75%]); nasofrontal subtypes were seen in 34 cases (8.5%) and nasoorbital in 14 cases (1.5%). The mean operative time was 2 h (range 30 min-3 h). There were only two patients (0.5%) needed postoperative blood transfusions. Mean hospitalization time was 5 days (range 4-7 days). Overall, complication rate in our series was 12.5%, mostly was CSF leakage and wound dehiscence.

CONCLUSION

The current socioeconomic conditions and local facility should be considered to treat these specific disease processes. The refined and meticulous technique, especially in choosing the approach and handling the dural closure, is essential in lowering the complication rate.

Surgical correction of grade III hypertelorism

Orbital hypertelorism is an increased distance between the bony orbits and can be caused by frontonasal malformations, craniofacial clefts, frontoethmoidal encephaloceles, glial tumors or dermoid cysts of the root of the nose, and various syndromic or chromosomal disorders. We report a series of 7 cases of hypertelorism that were treated in our hospital. The underlying causes in our series were craniofacial clefts 0 to 14 (4 cases), craniofacial clefts 1 to 12 (1 case), and frontonasal encephalocele (2 cases), all congenital. Surgical techniques used to correct the deformity were box osteotomy and medial wall osteotomy with or without calvarial and rib grafts. A few of our cases were reoperations with specific challenges.

Naso-ethmoidal encephalocele with bilateral orbital extension: report of a case in a western country

INTRODUCTION

Encephalocele is a rare congenital malformation of the central nervous system with protrusion of cranial content (meninges, brain, and ventricles in different combinations) beyond the normal confines of the skull. Anterior encephaloceles occur with a high frequency in Southeast Asia, while in the Western countries occipital encephaloceles prevail. The treatment of an anterior (naso-ethmoidal) encephalocele involves a neurosurgeon or a multidisciplinary team (neurosurgeon, maxillofacial surgeon, plastic surgeon, and ENT surgeon) dealing with craniofacial surgery. Goals of surgery include removal or repositioning of nonfunctional cerebral tissue, closure of the dura, and reconstruction of skeletal and cutaneous structures. The prognosis depends from the anatomical site, volume of neural contents, and the presence of coexisting malformations.

CASE REPORT

We report the case of an Italian child suffering from a naso-ethmoidal encephalocele with bilateral orbital extension. The surgical treatment was performed in two steps.

CONCLUSION

Sincipital encephalocele is a complex pathology without a unique standardized surgical treatment. Its low incidence in Western countries can make its management particularly tricky.

Purse-string closure for frontoethmoidal encephalomeningocele

BACKGROUND

Skin incision over the nose is routinely made for accessing the nasal structures, removing the mass, as well as resecting the redundant skin in patients with frontoethmoidal encephalomeningocele (FEEM). Unfortunately, the conventional elliptical excision leaves a long, straight-line scar that becomes a stigma of the disease.

OBJECTIVE

The author describes a purse-string closure technique for closure of the skin defect over the nasal dorsum in a patient with FEEM, which results in the reduction of a surgical scar.

METHODS

The skin overlying the encephalocele is pinched and marked around the mass. The skin is cut, and the encephalocele is dissected deep down the bony opening. Then a bicoronal scalp flap and frontal craniotomy and bilateral medial orbital walls osteotomies are performed. The encephalocele is removed at the neck, and the dural defect is repaired. The bony defect is repaired and bone-grafted as necessary. The skin defect is closed with double layers with the purse-string closure technique and crisscross mattress sutures.

RESULTS

: Between January 2004 and July 2009, a total of 7 FEEM patients underwent a 1-stage combined intracranial and extracranial repair and reconstruction of the deformity using the purse-string closure technique.

CONCLUSIONS

The purse-string closure technique as described provides an alternative skin closure for the repair and reconstruction of FEEM.

Frontoethmoidal meningoencephalocele: appraisal of 200 operated cases

OBJECT

Frontoethmoidal mengingoencephaloceles (fMECs) are frequently observed in Cambodia, especially in poor families. The authors describe issues related to the surgical treatment of fMECs in Cambodia at the end of a humanitarian program that provided surgery free of charge to patients and their families.

METHODS

The authors reviewed 257 cases of fMEC involving patients who presented to their institution, the Children's Surgical Center in Phnom Penh, between 2004 and 2009. They treated 200 of these patients surgically (108 males, 92 females; 89% younger than 18 years) using a "low-cost" management plan with no routine pre- or postoperative investigations. Initially, surgery was performed by visiting foreign surgeons who taught the procedures to resident surgeons. Patients were not charged for consultations or treatment and received at least 1 follow-up examination 6 months postoperatively.

RESULTS

The nasoethmoidal type was the most frequent fMEC encountered (69%). Many patients had associated ophthalmological issues (46% of cases). Only 1 familial case was detected. Combined neurosurgical and facial procedures were successfully standardized and learned by surgeons initially unfamiliar with fMEC management. A neurosurgical approach avoided the need for a facial incision in 42 cases, improving cosmetic results. The most common postoperative issues were a temporary CSF leak (24 cases [12%]) and/or infection (28 cases [14%]). There were 3 deaths directly related to the operations. Cosmetic results were good in 145 cases, average in 27, poor in 7, and worse than preoperative appearance in 6 patients. Fifteen patients were lost to follow-up. The parents of 87% of the children were rice farmers. Questionnaire results confirmed that fMEC has important social and educational consequences for the affected children and that these consequences can be partially improved by fMEC correction.

CONCLUSIONS

This experience in fMEC management demonstrates that local surgeons can treat these malformations with limited surgical materials and in a nonspecialized infrastructure after principles of treatment have been learned and if they are carefully respected. Surgery for fMEC can thus be more accessible to a larger number of patients in developing countries. Moreover, local treatment facilitates better postoperative and follow-up care.

Correction of frontonasoethmoidal encephalocele: the HULA procedure

BACKGROUND

The frontonasoethmoidal encephalomeningocele deformity involves central herniation of a glial mass that "pushes outward" and deforms the medial orbit, medial canthus, nasomaxillary process, and nasal structures without resulting in hypertelorbitism. The authors studied a modification of the "Chula" repair, called the HULA procedure (H = hard-tissue sealant, U = undermine and excise encephalocele, L = lower supraorbital bar, A = augment nasal dorsum), which provided complete correction of the midline hard and soft-tissue structures using an intracranial and extracranial approach.

METHODS

Filipino patients with frontonasoethmoidal encephalomeningoceles were treated by a civilian/military humanitarian team at Tripler Army Hospital (n = 12). Operative technique followed the four steps of the HULA frontoethmoidal encephalocele procedure. Postoperative and follow-up assessments were based on examination, photographic images, computed tomography scans, parental surveys, Whitaker score, and developmental testing.

RESULTS

Patient ages ranged from 5 to 12 years; 67 percent were female and 33 percent male. Sixty-seven percent required excisions of poor-quality, hyperpigmented skin along with the large glial mass; the other 33 percent had a "closed" resection of the smaller mass through a gingivobuccal sulcus incision. No patients manifested cerebrospinal fluid leaks, infection, or elevated intracranial pressures postoperatively. Skeletal correction showed improved medial orbit distance, with a mean correction of 14 mm (42 percent). Whitaker score was 1.3 (no or minor soft-tissue revision necessary). Parental survey showed a high degree of satisfaction with the aesthetic and functional outcomes. Follow-up developmental tests showed normal global evaluations for all but one child with normal memory and attention skills.

CONCLUSION

The authors' outcomes demonstrated that the HULA technique was a safe and effective approach for the complete correction of frontonasoethmoidal encephalomeningoceles.

Telecanthus and hypertelorism in frontoethmoidal meningoencephaloceles and the surgical correction of these conditions: Part II. A novel surgical approach in the treatment of telecanthus

Frontoethmoidal meningoencephaloceles (MEC) are frequently associated with telecanthus (TC) and seldom with hypertelorism (HT). The correction of these orbital dysmorphisms are undertaken in the same setting as the surgical treatment of MEC. During several charity missions to Phnom Penh, Cambodia, the authors developed a simple surgical technique for the correction of TC that has not been described before. The results of this technique was evaluated as follows: in 58 patients, who underwent surgical treatment of MEC, the pre and postoperative inner canthal (ICD) and outer canthal distances (OCD) were measured; the interpupillary distance (IPD) was measured in 50 patients. Forty five (78%) out of the 58 patients showed a telecanthus before surgery; 39 (87%) of these 45 showed normal values after surgery, in the rest 6 (13%) the ICD could be decreased after surgery, however the values did not reach a normal range.A HT (including TC) was found in 10 patients presenting with MEC (17%) before surgery. Five (50%) of these patients did not show a HT in post surgical follow-up. In 3 (30%) of the remaining 5 patients showing persistent HT, the ICD alone could be decreased to a normal value (no TC), whereas in 2 (20%) others a TC was unchanged. Three patients with MEC had shown normal preoperative orbital morphometry. The mean follow-up was 9 months (range: 5-16 months). The reader is further referred to our previous paper for interpreting the orbital measurement values in Khmer Cambodians as pertinent to TC or HT.