RU2512782C1 - Method for surgical management of liquorrhea nasalis - Google Patents

Method for surgical management of liquorrhea nasalis Download PDF

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Publication number
RU2512782C1
RU2512782C1 RU2012155776/14A RU2012155776A RU2512782C1 RU 2512782 C1 RU2512782 C1 RU 2512782C1 RU 2012155776/14 A RU2012155776/14 A RU 2012155776/14A RU 2012155776 A RU2012155776 A RU 2012155776A RU 2512782 C1 RU2512782 C1 RU 2512782C1
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frontal sinus
olfactory
frontal
fissure
posterior
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RU2012155776/14A
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Russian (ru)
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Александр Вадимович Горожанин
Александр Евгеньевич Константинов
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Александр Вадимович Горожанин
Александр Евгеньевич Константинов
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Abstract

FIELD: medicine.
SUBSTANCE: defect of an olfactory fissure is repaired from an endoscopic intracranial minimally invasive approach to the olfactory fissure that is provided by incising along a skin fold in a projection of an inferomedial frontal lobe depending on the patient's characteristics. The mucosa is removed from a frontal sinus through a frontal sinus orifice of an anterior wall. A fragment of a posterior wall of the frontal sinus in a paramedian direction in a basal frontal sinus to form a duplication. A dura mater is stripped from the olfactory fissure, and an autogenous bone is laid into a bone bed of the olfactory fissure shaped thereafter. The autogenous bone is covered with an Indost plate and the dura mater duplication separated earlier; the repair region is sealed with Tissucol-KIT fibrin two-pack glue that is followed by the plastic repair of the posterior and anterior walls of the frontal sinus.
EFFECT: method enables providing higher clinical effectiveness ensured by using the minimally invasive transcranial approaches to a base of the cranial fossa.
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Description

The invention relates to the field of clinical medicine, namely to the field of neurosurgery and otorhinolaryngology.

It is known that the main methods of treating this pathology are plastic source of liquorrhea with traditional subfrontal and endonasal endoscopic access. When performing transcranial interventions with traditional subfrontal, often bilateral, access, the surgeon faces a number of problems (cranialization of two frontal sinuses, closure of both nasal-frontal anastomoses, limited angle of retraction of the basal parts of the frontal lobes). In this regard, a high risk of purulent-inflammatory complications and post-refractive damage to the basal parts of the frontal lobes. The disadvantages of using endoscopic access include gross violations of the architectonics of the nasal cavity during the operation, less reliable plastic surgery than intracranial access due to the inability to close the dura mater defect (TMT), and a high risk of liquorrhea recurrence in the long-term postoperative period due to the risk of development necrosis and lysis of soft and cartilage tissues used in endoscopic endonasal plastic surgery, after suffering purulent rhinitis in the outcome of acute respiratory viral infections.

A known method for plasticizing defects in the base of the skull, including the use of intracranial and endonasal approaches and closing the defect of the base of the skull with free autografts with fixation with their bio-adhesive, consists in first intracranially closing the bone defect of the base of the skull with an autocostal fragment wrapped in an autofascial flap, treated with a bioptic flap on top autogyro tissue is laid, then endonasal, transsphenoidal, transetmoidal access to the skull base defect is used outside, they perform plastic surgery with an auto-fat-muscle-fascial flap treated with bio-adhesive, while the edges of the fascial autograft flap are inserted beyond the edges of the bone defect of the base of the skull and are additionally fixed with the middle nasal concha, which is deepithelialized from the lateral side, mobilized and displaced laterally (see, for example, description of the invention to the patent of the Russian Federation No. 2402284, class A61B 17/00, publ. 10.27.2010).

However, this method does not provide surgical treatment of nasal liquorrhea from the olfactory gap with minimally invasive intracranial access.

A known method of plasticity of a defect in the front wall of the frontal and maxillary sinus, including fixing the graft from the flat bone of the cranial vault of the human fetus to the bone walls of the frontal and maxillary sinuses, and the fixation is carried out by "biological" welding by radiation of the ATKUS-15 semiconductor laser using the contact method of the distal end part of the end face with an output power of 8 W radiation in constant mode (see, for example, the description of the invention to the patent of the Russian Federation No. 2239385, CL A61B 18/20, publ. 10.11.2004).

The disadvantages of this method include the need to use a biological tissue connection using welding, requiring high qualifications and a long time.

The closest known method is the surgical treatment of nasal liquorrhea, which consists in excising the mucous membrane of the fistulous passage by thermal exposure and then closing the site of exposure, while additionally performing the effect on tissues adjacent to the fistulous passage performed in one session with excision, both effects are carried out using a high-intensity laser radiation of a diode laser with a wavelength of 0.97 microns with a power of 3-4 W in a continuous mode, the total exposure time to mucus fifth fistulous tract and surrounding tissue is 3-5 minutes and closing automaterialom impact position is performed (see., e.g., specification of a patent RF №2346667, cl. A61B 18/20, publ. 20.02.2009).

The disadvantages of this method are the limited possibilities associated with the impossibility of surgical treatment of nasal liquorrhea from the olfactory gap and meningocele, the need to use biological tissue joining using laser welding, which requires high qualification and a long time, as well as the relatively low outcome of successfully performed operations, not exceeding 70 %

The technical result of the invention is to expand the functionality of the method due to the possibility of treatment from the olfactory gap and meningocele, increasing the effectiveness of treatment by a reliable and more effective method of treating liquorrhea and meningocele from the olfactory gap using minimally invasive transcranial access to the base of the anterior cranial fossa, in accordance with the concept and surgical technique Keyhole - Access and using modern osteoinductors and composite materials.

The indicated technical result is achieved by the fact that in the method of surgical treatment of nasal liquorrhea, in which the olfactory gap defect is plasticized with endoscopic intracranial minimally invasive access to the olfactory gap, in order to ensure that, depending on the individual characteristics of the patient, an incision is made along the skin fold under the eyebrow or over the eyebrow, or a vertical incision in the Glabellae region, or an arcuate incision at the medial edge of the orbit, removes the mucosa from the frontal sinus through the frontotomy from an aperture of the anterior wall, remove a fragment of the posterior wall of the frontal sinus paramedianally in the basal part of the frontal sinus with the formation of a duplicature, exfoliate the dura mater from the olfactory fissure, lay the autocost in the bone bed of the olfactory fissure according to its shape, and on top of the autobone lay the Indosta plate and the duplicate gland shell and seal the plastic zone with a two-component fibrin glue Tissukol-KIT, after which plastic surgery of the posterior and anterior walls of the frontal sinus is performed.

The claimed combination of essential features is in direct causal relation to the achieved result.

Comparison of the claimed technical solution with the prototype made it possible to establish compliance with its criterion of "novelty", since it is not known from the prior art. The proposed method is industrially applicable in medicine by existing technical means and meets the criterion of "inventive step", since it does not explicitly follow from the prior art.

Thus, the proposed technical solution meets the established conditions of patentability of the invention.

The proposed method for the surgical treatment of nasal liquorrhea from the olfactory gap and meningocele is as follows.

Several minimally invasive endoscopic approaches to the base of the anterior cranial fossa are used: lateral supraorbital, medial variation of supraorbital access, as well as transfrontal access through the posterior wall of the frontal sinus and transglabellar.

Based on our experience, two minimally invasive endoscopic approaches are most convenient for plasty of cerebrospinal fluid fistulas from the olfactory fissure - transfrontal through the frontal sinus and medial variation of the supraorbital access.

A skin incision before surgery is performed depending on the individual characteristics of the patient and taking into account the cosmetic result. The following incision options are used, which are selected individually: an incision is made under the eyebrow 2 cm long, a vertical incision is made in the skin fold in the projection area of the lower medial part of the frontal bone (in the Glabellae region), an incision is made in the skin fold above the eyebrow, and the incision is arched at the medial orbit. After detachment of the soft tissues and periosteum with a chisel, plates of the cortical layer of the frontal bone are formed with a chisel for subsequent plasty.

After the formation of the bone window over the TMT of about 0.7-1.0 cm in size under endoscopic control, the TMT is detached from the bottom of the anterior cranial fossa in the area of the orbital roof to the margin of the upper orbital fissure in the posterolateral direction, above the nose roof to the olfactory fissure in the medial direction, the upper wall of the main sinus 0.5-0.7 cm posterior to the posterior edge of the olfactory fissure. As a result of this, there is a good overview of the olfactory gap with virtually no traction of the frontal lobes.

TMT exfoliate from the lateral edge of the olfactory fissure, having a direction close to vertical, and from the posterior edge of the olfactory fissure. After cutting off the lateral and posterior edges of the TMT using angular scalpels and microsurgical scissors - the TMT must be cut as low as possible - the TMT is detached from Crista gallae and the posteromedial part of the nose roof. After the TMT is cut off from the medial edge of the olfactory fissure and retracted upwards, the TMT forms duplicature on the arachnoid membrane. In all observations, the olfactory zone did not look like a sieve-like plate, but a bone slit-like defect about 0.3-0.5 cm wide in the anterior and in the posterior, sometimes up to 0.7 cm.

The bone grafting of the olfactory gap is carried out with autobone fragments taken either from the external and internal cortical layer of the frontal bone, or with material taken from the bone section of the nasal septum. Optimal surface matching can be achieved by placing fragments of the crest of the posterior part of the nasal septum in the olfactory fissure treated with a chisel or boron in the form of the olfactory fissure.

With a large depth of the anterior olfactory fissure, autobone fragments are laid in two layers. Indoste osteoinducer plates are placed on top of the autobone to form a more even contour of the bottom of the anterior cranial fossa.

Between the bone grafting zone and TMT, a thin layer of Tissucol-KIT fibrin two-component adhesive is applied.

Leaving the surgical field is carried out depending on the specific anatomical features of the patient. The final stages of the operation have the following options.

After laying a bone fragment of the posterior wall of the frontal sinus in its place with a snug fit and a large thickness of the posterior wall of the frontal sinus, additional processing of the edges is not required. With a thin back wall of the frontal sinus, the edge of the flap can be covered with a small layer of fibrin-thrombin glue.

The lumen of the frontal sinus in some cases can be maintained by laying a bone fragment of the anterior sinus wall in its place.

In one observation, with a small depth of the frontal sinus, the anterior wall was removed and an expanded periosteal flap of the upper frontal region and the skin of the anterior wall were placed on the posterior wall.

We also used obliteration of the frontal sinus with the osteoinductors Indostom and Kollapol with plastic surgery of the anterior wall by a titanium mesh sprayed with BioSital or autobone with fixation by titanium microplates.

With a rather pronounced hypoplasia of the frontal sinus, it can be cranilized with plastic of the natural anastomosis with autologous bone and small fragments of Collapol and Indostus.

The extradural transcranial endoscopic method of plasty has significant advantages over endonasal approaches, since it is reliable, intranasal anatomy is not violated, there is no synechia in the nasal cavity and the risk of violating the integrity of the roof of the nose in acute purulent rhinitis is slightly higher than in a healthy person. It is especially important that with intracranial access it is possible to reliably seal the TMT, while at the same time preventing the adhesion process between the arachnoid membrane and the basal surface of the skull, which can lead to impaired cerebrospinal fluid dynamics. On the other hand, the method has an advantage over standard neurosurgical options for plastic surgery of the bottom of the anterior cranial fossa as less traumatic, with a good cosmetic effect, which allows to keep the patient's sense of smell. In all cases, a good cosmetic result was achieved. Endoscopic minimally invasive intracranial methods of treating this pathology make it possible to creatively use various modifications depending on the individual anatomical features of the patient, which significantly improves the immediate and long-term results of treatment.

The proposed method is illustrated by the following examples of surgical treatment in the hospital department of neurosurgery No. 19B of the Moscow city clinical hospital named after S.P. Botkin.

Example 1. Patient Akimova AA, 63 years old, was admitted with a diagnosis of meningocele of the main sinus and posterior cells of the ethmoid bone, nasal liquorrhea, complicated by the development of purulent meningitis. Complaints of mild headache, nasal discharge. Over the course of 8 years, he notes the release of a clear, colorless liquid from the right nasal passage. The last 4 years of allocation are constant. Initially, this condition was regarded as vasomotor rhinitis. Then, nasal liquorrhea was diagnosed, and purulent meningitis later developed. Surgical treatment: under KETN, after treatment of the skin with antiseptic solutions, a linear incision was made along the lower edge of the left eyebrow 2 cm. After detachment of the skin with the periosteum, laterally the ocular cox of the left frontal sinus, moderately hypoplastic, a 1.0 mm x 0.7 cm hole was placed in the front the lower wall of the frontal bone. Cortical plates are taken for subsequent plastic surgery of the roof of the nose. After separation of the TMT, which was sharply thinned with a pronounced pulsation and in places fusion with the bottom of the PCF, a bone defect was visualized in the area of the olfactory fissure 2 cm long and 0.7-1 cm wide in the posterior region. The edges of the meninges extending into the nasal cavity were dissected. mobilized upward with the formation of duplication. Bone fragments of the cortical layer were laid in place of the defect, a periosteal flap on a leg from the left half of the frontal bone was cut out and additionally inserted into the TMT in the anteroposterior region due to its sharp thinning. Between the bone fragments laid on the roof of the nose and the site of TMT plastic surgery, Tissukol-KIT glue was introduced. Stitches on the wound. The second stage after lateroposition of the left median nasal shell is the dissection of the walls of the meningocele. At the location of the meningocele, there is a resorption of the posterior cells of the ethmoid bone to the perpendicular plate of the middle nasal concha, the front wall of the main sinus extends into its lumen, and therefore the natural anastomosis of the main sinus is expanded in the lateral direction. Bleeding is slight. It stopped on its own. Merocele swab is inserted into the nasal cavity.

Examination: CT scan of the brain: state after surgery for endoscopic meningocele plastic surgery - the median structures are not displaced, convexital fissures are not expanded, the skull bones are not changed, the cisterns of the base are not expanded, the defect covered by the bone plate is identified in the area of the lattice labyrinth, there are no focal changes, there is no pneumocephaly.

Last condition: satisfactory.

Example 2. Patient Shavlova E.E., 49 years old, diagnosis: meningocele of the left half of the nasal cavity, nasal liquorrhea. Complaints of a headache in the frontal region, fluid outflow, mainly from the left half of the nose, aggravated by tilting the head forward. Surgical treatment: under KETN, after treatment of the skin with antiseptic solutions, a linear incision was made along the skin fold of 2 cm of the left frontal region. A hole 1 × 0.7 cm in the front wall of the frontal sinus is superimposed with a chisel. The frontal sinus is small, after removing the mucosa to the natural anastomosis, the posterior wall of the frontal sinus has been removed. After separation of the TMT, a bone defect is visualized in the area of the olfactory fissure with a size of 0.8 × 1.7 cm. The edges of the meninges extending into the nasal cavity are dissected, mobilized upward with the formation of duplication. The walls of the hernial sac are removed from the nasal cavity. There are no signs of liquorrhea. 2 large and 2 small fragments of autobone from the posterior wall of the frontal sinus were laid in place of the defect, 1.5 Indosta plates were placed on top of them, sealing with Tissukol-KIT glue. An autobone, 2 small plates of Indosta and a small double fragment of a titanium mesh sprayed with BioSital are laid in the area of natural anastomosis. A fragment of the anterior wall of the frontal sinus is laid in place. Layered seams on the wound. Merocele swab is inserted into the nasal cavity.

Thus, the proposed method provides enhanced functionality and increases the effectiveness of surgical treatment of nasal liquorrhea from the olfactory gap and meningocele.

Claims (1)

  1. A method of surgical treatment of nasal liquorrhea, characterized in that the olfactory gap defect is plasticized with endoscopic intracranial minimally invasive access to the olfactory gap, to ensure which, depending on the individual characteristics of the patient, an incision is made along the skin fold under the eyebrow or over the eyebrow, or a vertical incision in the Glabellae region, or an arcuate incision at the medial edge of the orbit, remove the mucosa from the frontal sinus through the frontotomy opening of the anterior wall, remove the fragment the posterior wall of the frontal sinus, paramedially in the basal part of the frontal sinus with the formation of duplicate, exfoliate the dura mater from the olfactory fissure, lay the autocost in the bone bed of the olfactory fissure in its shape, lay the Indosta plate on top of the autocost and duplicate the previously isolated dura mater and seal two-component glue Tissukol-KIT, after which plastic surgery of the posterior and anterior walls of the frontal sinus is performed.
RU2012155776/14A 2012-12-24 2012-12-24 Method for surgical management of liquorrhea nasalis RU2512782C1 (en)

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Cited By (6)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
RU2570619C1 (en) * 2014-05-22 2015-12-10 Анастасия Игоревна Рябова Method for repairing extensive defect of bottom of anterior cranial fossa
RU2598457C1 (en) * 2015-07-22 2016-09-27 Федеральное государственное бюджетное учреждение "Санкт-Петербургский научно-исследовательский институт уха, горла, носа и речи" Министерства здравоохранения Российской Федерации (ФГБУ "СПб НИИ ЛОР Минздрава России") Method for plastic repair of basicranial bone defects
RU2635633C1 (en) * 2017-03-23 2017-11-14 Алексей Николаевич Шкарубо Method of plastics and sealing defects of dura in the field of bone defect of base of skull
RU2635862C1 (en) * 2016-05-30 2017-11-16 Государственное автономное учреждение здравоохранения "Республиканская клиническая больница Министерства здравоохранения Республики Татарстан" Method of surgical treatment of patients with arnold-chiari malformation
RU2647620C1 (en) * 2017-03-01 2018-03-16 Федеральное государственное бюджетное образовательное учреждение дополнительного профессионального образования "Российская медицинская академия непрерывного профессионального образования" Министерства здравоохранения Российской Федерации (ФГБОУ ДПО РМАНПО Минздрава России) Method of lymphorrhea prevention after radical prostatectomy
RU2655784C1 (en) * 2018-01-09 2018-05-29 Алексей Николаевич Шкарубо Method of plastic repair and sealing of pachymeninx defects in bone loss area in the skull base

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Cited By (6)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
RU2570619C1 (en) * 2014-05-22 2015-12-10 Анастасия Игоревна Рябова Method for repairing extensive defect of bottom of anterior cranial fossa
RU2598457C1 (en) * 2015-07-22 2016-09-27 Федеральное государственное бюджетное учреждение "Санкт-Петербургский научно-исследовательский институт уха, горла, носа и речи" Министерства здравоохранения Российской Федерации (ФГБУ "СПб НИИ ЛОР Минздрава России") Method for plastic repair of basicranial bone defects
RU2635862C1 (en) * 2016-05-30 2017-11-16 Государственное автономное учреждение здравоохранения "Республиканская клиническая больница Министерства здравоохранения Республики Татарстан" Method of surgical treatment of patients with arnold-chiari malformation
RU2647620C1 (en) * 2017-03-01 2018-03-16 Федеральное государственное бюджетное образовательное учреждение дополнительного профессионального образования "Российская медицинская академия непрерывного профессионального образования" Министерства здравоохранения Российской Федерации (ФГБОУ ДПО РМАНПО Минздрава России) Method of lymphorrhea prevention after radical prostatectomy
RU2635633C1 (en) * 2017-03-23 2017-11-14 Алексей Николаевич Шкарубо Method of plastics and sealing defects of dura in the field of bone defect of base of skull
RU2655784C1 (en) * 2018-01-09 2018-05-29 Алексей Николаевич Шкарубо Method of plastic repair and sealing of pachymeninx defects in bone loss area in the skull base

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