A safer transnasal technique for the management of bilateral choanal atresia

AbstractA study was undertaken on a 3.2 kilogram fresh stillborn neonate, to determine ways and means of preventing damage to the skull base.Gruber and Rosen aural specula were inserted separately into the right nostril, to determine the degree of exposure of the choana with each. The position of the surgeon was varied (septoplasty versus tonsillectomy position), to determine on which anatomical site of the choana the surgeon's field of vision was focused.The Gruber aural speculum, gave a completely, uninterrupted view of the choana.In the tonsillectomy position, the entire field of vision was focused on the choana itself, whilst in the septoplasty position, one half was focused on the choana and the other half on the roof. Since the roof is part of the skill base, damage to this area can result in serious intracranial complications, such as CSF leak and meningitis.These complications can be avoided if the surgeon uses the Gruber aural speculum for exposure and operates from a tonsillectomy position.

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Pneumocephalus and CSF leak secondary to skull base fracture by pyrotechnical object: case report

Peruvian Journal of Neurosurgery ◽

10.53668/2021.pjns33175 ◽

2021 ◽

Vol 3 (3) ◽

Author(s):

Marcos Vilca ◽

◽

Carlos Palacios ◽

Sofía Rosas ◽

Ermitaño Bautista ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Pressure ◽

Skull Base ◽

Rare Complication ◽

Cerebrospinal Fluid Leak ◽

Standing Position ◽

Csf Leak ◽

Skull Base Fracture ◽

Timely Diagnosis ◽

The Right

Introduction: Pneumocephalus is mainly associated with traumatic injuries, being a rare complication but with high mortality rates; it behaves like a space-occupying lesion and increases intracranial pressure. The symptoms are not specific, but in the event of trauma it is necessary to suspect this entity to carry out a timely diagnosis and treatment, since being the product of the skull base fracture it can cause communication with the outside, and the appearance of cerebrospinal fluid (CSF) leak. Clinical Case: a 38-year-old male patient who suffers trauma from a pyrotechnic explosion near his right ear, when handling a pyrotechnic object (whistle) during the New Year, presenting severe pain, slight bleeding in the right ear, feeling faint and holocranial headache that increased in a standing position; likewise, he presents high-flow aqueous secretion (CSF) from the right ear. Brain and skull base tomography (CT) showed air in the intracranial cavity, fracture of the skull base, and the ossicles of the right middle ear. Conservative management was performed using rest and lumbar drainage, presenting a satisfactory evolution. Conclusion: Pneumocephalus is a frequent and expected complication of trauma with a skull base fracture. Its early and timely diagnosis using skull base CT is essential to define therapeutic measures. Accidents due to the misuse of pyrotechnics continue to be a relevant problem in our country. Knowing and disseminating its consequences can help raise awareness in the population. Keywords: Pneumocephalus, Skull Base, Intracranial Pressure, Cerebrospinal Fluid Leak. (Source: MeSH NLM)

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Bilateral Choanal Atresia Associated with Malformation of the Anterior Skull Base: Embryogenesis and Clinical Implications

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348949210101106 ◽

1992 ◽

Vol 101 (11) ◽

pp. 916-919 ◽

Cited By ~ 16

Author(s):

Michael E. Dunham ◽

Robert P. Miller

Keyword(s):

Skull Base ◽

Choanal Atresia ◽

Three Dimensional ◽

Anterior Skull Base ◽

Preoperative Imaging ◽

Clinical Implications ◽

High Resolution Computed Tomography ◽

Ethmoid Bone ◽

Intracranial Complications ◽

Skull Base Defect

A number of craniofacial and systemic malformations have been described in association with choanal atresia. We report a case of bilateral choanal atresia associated with congenital absence of the cribriform plate, crista galli, and perpendicular plate of the ethmoid bone. The anterior skull base defect was detected by using high-resolution computed tomography with three-dimensional reconstructions. The findings support the mesodermal flow theory of choanal atresia, in which there is excess migration of neural crest cells into the developing nasal septum and posterior choanae. This occurs at the expense of cells that would otherwise form the rest of the ethmoid complex. Clinical implications include the need for adequate preoperative imaging of the anterior skull base and consideration of potential intracranial complications during surgical repair.

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Don't sue the surgeon: remineralisation of the skull base or a defect that never existed?

The Journal of Laryngology & Otology ◽

10.1017/s0022215111001885 ◽

2011 ◽

Vol 125 (12) ◽

pp. 1294-1297

Author(s):

C Hopkins ◽

S Dhillon ◽

G Rogers ◽

D Roberts

Keyword(s):

Computed Tomography ◽

Skull Base ◽

Endoscopic Sinus Surgery ◽

Semicircular Canals ◽

Time Frame ◽

Sinus Surgery ◽

Operative Exploration ◽

Intracranial Complications ◽

Operative Findings ◽

The Right

AbstractIntroduction:Intracranial complications are recognised as rare, but serious, sequelae of endoscopic sinus surgery.Case report:A 56-year-old woman was referred after developing meningitis following elective functional endoscopic sinus surgery. Computed tomography demonstrated a significant defect of the skull base in the right posterior ethmoid, clearly visible on both coronal and sagittal sections. Operative exploration demonstrated the skull base to be intact in the posterior ethmoid area identified on the scan, and the overlying mucosa appeared undisturbed. Scans were reviewed in the light of operative findings; coronal and sagittal images were found to be reconstructions. Directly acquired coronal computed tomography, undertaken three weeks after surgery, demonstrated a complete bony plate in the right posterior ethmoid at the site previously identified as dehiscent.Discussion and conclusion:We speculate that the posterior ethmoid defect was actually an artefact of reconstruction. We cannot exclude the alternative possibility of remineralisation, but given the time frame this seems unlikely. This case highlights the need for caution when interpreting reconstructed images of the thin bony plates of the skull base and lamina papyracea, as regards both clinical significance and medicolegal reporting. While virtual defects have been reported in the superior semicircular canals as a result of reconstructed images, we believe this to be the first reported case demonstrating a similar problem in the anterior skull base.

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Management of an Unusual Intranasal Foreign Body Abutting the Cribriform Plate: A Case Report and Review of Literature

Clinical Medicine Insights Ear Nose and Throat ◽

10.1177/1179550619858606 ◽

2019 ◽

Vol 12 ◽

pp. 117955061985860

Author(s):

Mingyang L Gray ◽

Catharine Kappauf ◽

Satish Govindaraj

Keyword(s):

Foreign Body ◽

Skull Base ◽

Foreign Bodies ◽

Cribriform Plate ◽

Sinus Surgery ◽

Csf Leak ◽

Intracranial Involvement ◽

History Of ◽

Initial Imaging ◽

The Right

A 35-year-old man with history of schizophrenia presented 3 weeks after placing a screw in his right nostril. Initial imaging showed a screw in the right ethmoid sinus with the tip penetrating the right cribriform plate. On exam, the patient was hemodynamically stable with purulent drainage in the right nasal cavity but no visible foreign body. While most nasal foreign bodies occur in children and are generally removed at the bedside, intranasal foreign bodies in adults tend to require further assessment. The foreign body in this case was concerning for skull base involvement and the patient was brought to the operating room (OR) with neurosurgery for endoscopic sinus surgery (ESS) and removal of foreign body. The screw was removed and the patient recovered with no signs of cerebrospinal fluid (CSF) leak postoperatively. Any concern for skull base or intracranial involvement should call for a full evaluation of the mechanism of injury and intervention in a controlled environment.

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Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries

PLoS ONE ◽

10.1371/journal.pone.0245119 ◽

2021 ◽

Vol 16 (3) ◽

pp. e0245119

Author(s):

Giuseppe Di Perna ◽

Federica Penner ◽

Fabio Cofano ◽

Raffaele De Marco ◽

Bianca Maria Baldassarre ◽

...

Keyword(s):

Skull Base ◽

Surgical Approach ◽

Leak Rate ◽

Low Flow ◽

Csf Leak ◽

Anatomical Site ◽

Skull Base Tumor ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Rate Analysis

Introduction Post-operative CSF leak still represents the main drawback of Endoscopic Endonasal Approach (EEA), and different reconstructive strategies have been proposed in order to decrease its rate. Objective To critically analyze the effectiveness of different adopted reconstruction strategies in patients that underwent EEA. Materials and methods Adult patients with skull base tumor surgically treated with EEA were retrospectively analyzed. Data recorded for each case concerned patient demographics, type of surgical approach, histotype, anatomical site of surgical approach, intra-operative CSF leak grade (no leak (INL), low flow (ILFL), high flow (IHFL)), reconstructive adopted strategy, Lumbar Drain positioning, post-operative CSF leak rate and intra/post-operative complications. Results A total number of 521 patients (January 2012-December 2019) was included. Intra-operative CSF leak grade showed to be associated with post-operative CSF leak rate. In particular, the risk to observe a post-operative CSF leak was higher when IHFL was encountered (25,5%; Exp(B) 16.25). In particular, vascularized multilayered reconstruction and fat use showed to be effective in lowering post-operative CSF leaks in IHFL (p 0.02). No differences were found considering INL and ILFL groups. Yearly post-operative CSF leak rate analysis showed a significative decreasing trend. Conclusion Intra-operative CSF leak grade strongly affected post-operative CSF leak rate. Multilayer reconstruction with fat and naso-septal flap could reduce the rate of CSF leak in high risk patients. Reconstructive strategies should be tailored according also to the type and the anatomical site of the approach.

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Endoscopic transtuberculum transplanum approach to suprasellar meningiomas

QJM ◽

10.1093/qjmed/hcaa055.008 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

A Elsawy ◽

S Hamada ◽

H Ibrahim ◽

O Yousef ◽

H Elhusseiny

Keyword(s):

Skull Base ◽

Surgical Repair ◽

Visual Outcome ◽

The Other ◽

Gross Total Resection ◽

Csf Leak ◽

Viable Option ◽

Total Resection ◽

Extended Endoscopic Approach ◽

Brain Retraction

Abstract Introduction Extended endoscopic approaches to suprasellarmeningiomas have been proposed recently as a viable option or alternative to traditional microsurgical transcranial approaches. Endoscopic approaches have been presented as a minimally invasive route to such formidable lesions of the skull base, obviating the need of large craniotomies & brain retraction. Endoscopic approaches were shown to provide comparable rates of gross total resection, in selected cases, better visual outcomes than transcranial approaches, on the other hand high CSF leak rate was a major cornerstone for criticism for endoscopic approaches. Objective Assessing the feasibility & safety of extended endoscopic approaches to suprasellarmeningiomas. Methods Interventional prospective study including 23 patients harboring suprasellarmeningiomas assessed for gross total resection, visual outcome, CSF leak rates & other surgical morbidities. Results 23 patients 18 females (78%) & 5 males (22%); mean age was 59 years with range of 37-86 years. Tuberculumsellae meningioma compromised 15 cases (65%), planumsphenoidale 2 cases (9%) &planum/tuberculum 6 patients (26%) of the studied patients. Gross total resection wash achieved in 17 patients (74%).Vision was improved in 80% of patients presenting with visual symptoms & was stable in 20% post-operatively. All patients (100%) without pre-operative visual deficit were able to preserve their pre-operative visual state. CSF leak was the most common compilation occurring in 4 patients (17%). Lumbar drainage was sufficient to control the CSF leak in 2 patients while the other 2 patients required surgical repair of the skull base reconstruct. Transient DI was encountered in 2 patients (9%). Conclusion Extended endoscopic approach to suprasellarmeningiomas is safe & feasible. Comparable outcomes regarding gross total resection with superior visual outcome can be attained in carefully selected patients. CSF leak is major limitation of endoscopic approaches, however the introduction of vascularized naso-septal flaps helped overcome this issue.

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