Cerebrospinal fluid rhinorrhea and otorrhea repair

Cerebrospinal fluid leakage associated with skull base fracture accounts for about 2% of closed head injury and about 5% of skull fracture. The fracture involving the frontal sinus, ethmoid sinus, sphenoid sinus and even the bone can form a rhinorrhea, but it is more common in the frontal sinus and ethmoid sinus. The fracture involves the cerebrospinal fluid leakage of the rock bone. If the tympanic membrane is intact, the cerebrospinal fluid can flow out of the nasal cavity through the eustachian tube to form a rhinorrhea. If the tympanic membrane ruptures at the same time, or the fracture line extends to the wall of the external auditory canal, the cerebrospinal fluid flows directly from the external auditory canal to form an ear leak. Most cerebrospinal fluid leakage can be cured by non-surgical treatment, but a few require surgical treatment. There are two approaches to the repair of cerebrospinal fluid leakage, one is the intradural approach and the other is the epidural approach. The advantage of the epidural approach is that the dura mater can not be cut, but its disadvantages are: 1 can make the dura mater increase, it is more difficult to repair the operation, the failure rate is high; 2 the surgery is limited, leakage The mouth can be missed; 3 postoperative extradural residual cavity is large, prone to infection. Therefore, in addition to the sphenoid sinus and part of the fracture of the rock can be used for the extradural approach, for the incidence of high frontal sinus and ethmoid sinus, as well as some fractures of the rock, the use of subdural surgery . Treating diseases: cerebrospinal fluid leakage Indication 1. The fracture of the fracture exceeds 3mm, and the leakage does not decrease for more than 1 week, or the leakage can not be self-healing for more than 1 month. 2. After conservative treatment has stopped fluid flow and then relapse, or cerebrospinal fluid leakage occurred in the late post-injury. 3. Those who have complicated purulent meningitis. 4. Combined with chronic sinusitis can not self-heal in the short term. Contraindications 1. The amount of cerebrospinal fluid leakage after injury is gradually reduced, and it is estimated that there is a possibility of cure. 2. The location of cerebrospinal fluid leakage is not clear. Preoperative preparation In addition to the general routine craniotomy preparation, it should also be performed according to the operation of different parts of the surgical otolaryngology surgery routine. Surgical procedure 1. Cerebrospinal fluid rhinorrhea repair from frontal sinus fracture (1) The bilateral coronal incision in the hairline of the forehead is used. Low bilateral bilateral frontal craniotomy. This incision facilitates the full visualization of the field and, if necessary, bilateral cranial fossa exploration. (2) The dural flap turns to the midline, and the frontal lobe is lifted upwards to reveal the anterior cranial fossa, looking for a leak. (3) Fully free the leak from the dura mater, suture it with a silk thread, and repair it with a fascia. (4) There is no special treatment for the linear fracture of the frontal sinus. For example, the frontal sinus is a comminuted fracture. The bone fragments should be removed from the epidural and the posterior wall of the frontal sinus should be removed. The frontal sinus mucosa should be pushed down the frontal canal. The nasal cavity closes the mucosa to the naked side. Or the entire sinus mucosa can be scraped off, and a thin rubber tube is sent to the nasal cavity through the nasal cannula for drainage. (5) Reset the bone flap and suture the incision. 2. Cerebrospinal fluid rhinorrhea repair from ethmoid sinus fracture (1) Because the fracture line passes through the two sides of the sieve plate, the same bilateral frontal bone craniotomy should be used. (2) The same leak is revealed in the dura mater and the frontal sinus fracture. (3) The suture of the silk thread is more difficult, and the fascia patch is often used for repair. (4) Conventional Guan. 3. Cerebrospinal fluid rhinorrhea repair from sphenoid sinus fracture Dural mucosa can be found on the sella, but it is incomplete and repairing is extremely difficult. It often fails to cover or fill the leak with the intracranial muscle. Therefore, it is best to use a method of transsphenoidal approach to muscle filling the sphenoid sinus to occlude the leak from the outside of the dura. In addition, a small number of sphenoid sinus gasification is far beyond the sphenoidal wing. When the skull base fracture involves the sphenoid wing, the cerebrospinal fluid can flow into the inner sinus of the large wing through the fracture line to form a cerebrospinal fluid rhinorrhea. At this time, because the pupil is not in the saddle and in the middle of the cranial fossa, the operation needs to lift the temporal lobe through the infraorbital approach, and repair the patch in the dura with a muscle piece or a fascia. 4. The cerebrospinal fluid leakage repair from the fracture of the rock bone involves the tympanic cap, which can cause ear leaks (when the tympanic membrane ruptures) or nasal leakage through the eustachian tube (when the tympanic membrane is intact). The dura mater can be present in the middle cranial fossa or in the posterior cranial fossa, or both. (1) If the leak is in the middle of the skull, the craniotomy is performed using the ankle bone flap. If the leak is in the posterior cranial fossa, the unilateral suboccipital incision bone window similar to the cerebellar pons approach is used for craniotomy. If there is a leak at the same time in the middle cranial fossa and the posterior cranial fossa Do the corresponding dura mater. (2) In the middle of the cranial fossa, lift the temporal lobe and find the leak at the bottom of the cranial fossa. In the posterior cranial fossa, the cerebellum is pulled inward and a leak is found behind the rock bone. There is a leak at the same time before and after the rock bone. It is necessary to cut the cerebellum along the rock bone. (3) Repair the leak. The repair of the leak hole is basically the same as the repair method of the leak hole in other parts, and the suture can be sutured when the dura mater can be sutured. Only the dural suture of this part is more difficult, and the method of covering the leak with the muscle film and the fascia in the dura mater is often used. (4) Close the skull as usual. A similar approach to otologic mastoidectomy can also be used to repair the dura mater and fill the leaks outside the epidural. 5. Repair of cerebrospinal fluid leakage in extensive cranial anterior fossa fractures For the extensive skull base and dural defects involving the cerebrospinal fluid leakage of the frontal sinus and ethmoid sinus can not be repaired by the general method, the transfer of the diaphragmatic fascia method (Gillespie, 1986) can be used for repair. (1) Coronal incision in the frontal hairline. (2) Flip the flap forward: the periosteum should be as thick as possible. For this purpose, a 0.5% procaine solution can be injected under the cap fascia to facilitate separation. (3) Design the size of the periosteal flap as needed to cover the defect area. Cut it from both sides of the midline, separate it from the skull, and connect it to the temporal fascia when it is on both sides of the crotch. (4) Free diaphragm and fascia: free range, down to the tibia, anterior to the side wall of the eyelid, and then separated along the iliac muscle. Until completely free and can move forward. (5) bilateral bilateral frontal bone flap craniotomy: ligation at the lower front, cutting the superior sagittal sinus, turning the dura mater to the back. The bilateral frontal lobe is retracted backwards to reveal the anterior cranial fossa. (6) Debridement: remove the broken bone piece, free and trim the defect of the dura mater, and treat the damaged sinus mucosa according to general principles. (7) repair defect: the periosteum-temporomandibular fascia combined flap was loosely laid in the defect, and it was tightly sutured with the dura mater with wire break. (8) After the repair is completed, the flushing test is performed. Rinse repeatedly with saline to see if any fluid is flowing out of the nasal cavity. If there is a leak, find the leak and then sew it tightly. (9) Check the suture and stratify the skull. complication 1. Incision infection. 2. Meningitis. 3. Cerebrospinal fluid leakage recurrence after surgery. More related to the lack of repair.

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