RU2598457C1 - Method for plastic repair of basicranial bone defects - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to otorhinolaryngology. Method comprises performing transseptal access to wedge-like pocket using endovideoscopic equipment, repair of CSF fistula, performed successively first by means of free autograft, and then nasoseptal vascularised mucoperichondrial flap on vascular pedicle, vascularised by rear septal artery. Said flap is and lumber drainage are fixed. Free autograft used is a fragment of quadrangular cartilage, which is brought behind edge of CSF fistula extradurally. Fixed by means of fibrin glue, and on top of free autograft, a "Tachocomb" sponge is placed, wherein nasoseptal vascularised mucoperichondrial flap is formed before repair of CSF fistula.

EFFECT: method enables reliable repair of CSF fistula of lateral wall of wedge-like sinus, conveniently form nasoseptal vascularised mucoperichondrial flap, freely manipulate in a surgery field without additional operations.

2 cl, 2 ex, 12 dwg

Description

The invention relates to medicine, namely to otorhinolaryngology, and may find application in plastic surgery of bone defects of the base of the skull, accompanied by nasal liquorrhea - cerebrospinal fistulas.

Nasal liquorrhea is a serious disease associated with a violation of the integrity of the natural anatomical barriers of the base of the skull, characterized by the outflow of cerebrospinal fluid from the nasal cavity.

The causes of nasal liquorrhea can be various. According to the frequency of occurrence, the first place among them is occupied by traumatic brain injuries (80-90%). There are also nasal liquorrhea of iatrogenic origin that occurs after surgical interventions in the nasal cavity and paranasal sinuses, neurosurgical operations for neoplasms of the brain and the base of the skull. A separate group consists of spontaneous nasal liquorrhea, the causes of which may be the pathology of inflammatory, degenerative, dysebriogenetic, tumor genesis, intracranial hypertension.

Liquor fistula can appear due to a bone defect located in the sieve plate of the ethmoid bone, the roof of the ethmoid labyrinth, and the frontal and sphenoid sinuses.

Due to the communication of the cerebrospinal fluid spaces of the cranial cavity with the external environment by means of the cerebrospinal fluid fistula with nasal liquorrhea, such formidable complications as secondary purulent meningitis, an abscess of the brain and cerebellum are possible, with a mortality rate of 25 to 50%.

There are conservative and surgical treatments for nasal liquorrhea. However, at present, the most optimal treatment methods for nasal liquorrhea are surgical methods for closing the cerebrospinal fluid.

A known method of endonasal plastic surgery of the cerebrospinal fluid fistula in the sphenoid sinus using the endoscopic technique (see S. Schmerberetal "Endonasal Endoscopic Closure of Cerebrospinal Fluid Rhinorrhea", Skull Base, 2001, v. 11, No. 1, p. 47-57).

When using this method, surgery is performed under endoscopic control. Perform direct transnasal sphenotomy. The natural anastomosis of the sphenoid sinus on the side corresponding to the localization of the cerebrospinal fluid fistula is expanded to the size necessary to visualize the bone defect. The defect of the base of the skull is visualized, de-epithelialization is performed around the defect. A free transplant of adipose tissue is placed opposite the dura mater defect and fixed with fibrin glue. Then the sinus is totally blocked with adipose tissue through an expanded natural anastomosis.

The disadvantage of this method is a higher recurrence rate compared with the methods of using a vascularized flap due to the possible premature resorption of adipose tissue, and the lack of blood supply in free flaps can lead to their failure.

This method is suitable for plastic surgery of only small bone defects.

There is also a method of endonasal plasty of cerebrospinal fluid fistula in the sphenoid sinus using free allografts (see Nathan B. Sautteretal "Endoscopic Management of Sphenoid Sinus Cerebrospinal Fluid Leaks", Annals of Otology, Rhinology & Laryngology, 2008, v. 117, No. 1, p. 1 . 32-39).

This method is implemented as follows.

Plastic surgery of the cerebrospinal fluid fistula is performed using free allografts ("AlloDerm"). The natural anastomosis of the sphenoid sinus on the side corresponding to the localization of the cerebrospinal fluid fistula is expanded to the size necessary to visualize the bone defect. The defect of the base of the skull is visualized, de-epithelization is performed around the fistula to determine the exact size of the defect of the base of the skull. Apply the technique of multilayer closure of the defect of the base of the skull using free flaps. The main layer is formed from a cell-free dermal matrix ("AIloDerm"), which is a free allograft. This flap is modeled according to the size of the defect and laid according to the “underlay” technique between the bone structures of the base of the skull and the dura mater. The next layer of the same material is placed on top of the defect on the lateral wall of the sphenoid sinus. For large defects (more than 10 mm), additional flaps from cartilage or bone tissue of the nasal septum are additionally used. The surface layer is formed from a free flap of the mucous membrane. For sealing use fibrin glue. Tamponade is performed with absorbable hemostatic materials.

The disadvantage of this method is the high recurrence rate due to possible rejection of allografts. The lack of blood supply in the used free flap of the mucous membrane increases the likelihood of necrosis. The use of direct transnasal access limits the visualization of the lateral sections of the sphenoid sinus and the ability to freely manipulate in the lumen of the sinus.

The closest in technical essence to the claimed solution is a method of closing the liquor fistulas using a nasoseptal vascularized mucoperichondrial flap (see Ivan H. El-Sayed et al., “Endoscopic Reconstruction of Skull Base Defects with the Nasal Septal Flap”, Skull Base, 2008 , v. 18, No. 6, p. 385-394).

This method is as follows.

Plastic surgery of the cerebrospinal fluid fistula is performed by a nasoseptic vascularized mucoperichondrial flap on the feeding vascular pedicle, which is supplied with blood by the posterior septal artery. The operation is performed under endovideoscopic control.

After lateralization of the middle nasal concha, a flap of the mucous membrane of the nasal septum is cut out on the side corresponding to the localization of the cerebrospinal fistula, as follows: using a monopolar electric knife, a horizontal incision is made in the mucous membrane of the nasal septum at its base, from the choanas along the bottom of the nasal cavity to 1.5 cm proximal to the anterior septal margins.

Then perform a front vertical incision up to a level of 1.0-1.5 cm below the arch of the nasal cavity. The upper horizontal section is made from the upper edge of the front section parallel to the arch of the nasal cavity to the front wall of the sphenoid sinus. Visualize the natural anastomosis of the sphenoid sinus.

The mucous membrane is separated from the anterior wall of the sphenoid sinus between the natural anastomosis from above and the choans from below to the level of projection of the sphenoid-palatal opening, thus forming the vascular pedicle of a nasoseptal vascularized mucoperichondrial flap. The resulting flap is taken into the nasopharynx.

The cerebrospinal fluid fistula is closed using a collagen matrix (Duragen), deeply inserted into the dura mater, then a free flap of adipose tissue is placed on top, which is fixed with fibrin glue, then a nasoseptic vascularized mucoperichondrial flap fixed with DuraS sealant is placed on the defect.

To fix the flap in the sinus, a Foley balloon catheter is used. The operation is completed with tamponade of the nasal cavity with Merocel sponges. Install extended lumbar drainage for 3-5 days.

The disadvantages of the method are:

- a rather narrow surgical field in the general nasal passage between the nasal septum and the middle nasal concha, as well as in the area of the sphenoetmoid pocket, which necessitates lateralization of the middle and upper nasal concha, and sometimes resection of the latter;

- insufficient visualization of the internal structures of the sphenoid sinus with direct unilateral sphenotomy, especially if there is increased pneumatization of the sinus;

- the use as a free flap of soft tissues (adipose tissue) increases the likelihood of recurrence of nasal liquorrhea with a size of the skull base defect of more than 10 mm.

The technical result of the proposed solution consists in combining an increase in the surgical field without additional interventions on the intranasal structures (middle and upper nasal concha), improving the visualization of all departments of the sphenoid sinus, and at the same time, in the reliable closure of the cerebrospinal fluid fistula larger than 10 mm.

To achieve the specified technical result in the method of plastic surgery of bone defects of the base of the skull, including endonasal access to the sphenoid sinus using the endovideoscopic technique, cerebrospinal fluid fistula performed sequentially first with free autografts, and then with a nasoseptic vascularized mucoperichondrial flap on the blood supply to the hepatic vasculature, fixation of said flap and lumbar drainage as suggested Produce transseptal access sphenoid sinus, as a free graft is used moiety quadrangular cartilage that give birth to the edges extradurally CSF fistulae, and nazoseptalny vascularized mukoperihondrialny flap formed before grafting CSF fistulae.

When implementing the proposed method, a nasoseptic vascularized mucoperichondrial flap is formed sequentially as part of an operative measure.

If in the prototype the specified flap is cut out at the very beginning of the operation and it is taken into the nasopharynx, then the flap is plastic with free flaps and subsequently the previously formed flap is laid, then in the claimed method the specified flap is formed not at the beginning of the operation, but after the plastic with free flaps, which avoids additional bleeding, increase the volume of the surgical field.

Transseptal access facilitates the formation of a nasoseptic vascularized mucoperichondrial flap due to previously performed separation of the mucous membrane of the nasal septum.

The inventive method allows you to reliably close cerebrospinal fluid fistula larger than 10 mm

The use of a fragment of a quadrangular cartilage as a free autograft, which is a denser tissue than adipose tissue and the collagen matrix, gives sufficient rigidity to the “structure” and allows closing defects of a larger size. Additional strength is achieved by installing the graft beyond the edges of the bone defect with additional fixation and sealing with fibrothrombin glue and a Tachocomb sponge.

Thus, the use of transeptal access to the sphenoid sinus in combination with combined plasty of the cerebrospinal fluid fistula with a nasoseptic vascularized mucoperichondrial flap of the mucous membrane of the nasal septum and a free autograft from the quadrangular cartilage can increase the surgical field without additional interventions on the intranasal structures (middle and upper nose), to improve all sections of the sphenoid sinus, perform reliable plasticity of the cerebrospinal fluid fistula.

The method is illustrated by drawings, where in FIG. 1 shows transeptal access to the sphenoid sinus; in FIG. 2 presents a cerebrospinal fluid fistula with a meningoencephalocele proliferating in the sinus lumen; in FIG. 3 shows the stage of preparation of the lateral wall of the sphenoid sinus for further plastic surgery of the cerebrospinal fluid; in FIG. 4 shows the plastic surgery stage of the defect in the bony wall of the sphenoid sinus with a free autograft from a quadrangular cartilage; in FIG. 5th stage of the formation of a nasoseptal vascularized mucoperichondrial nasal septum flap; in FIG. The 6th stage of cerebrospinal fluid fistula plasty with a nasoseptal vascularized mucoperichondrial flap.

In the drawings, the following positions were used: 1 - partially opened front wall of the sphenoid sinus; 2 - the lumen of the sphenoid sinus; 3 - the edges of the cerebrospinal fluid fistula; 4 - meningoencephalocele; 5 - a free autograft from a quadrangular cartilage; 6 - fibrintrombin glue "Tissucol"; 7 - sponge "Tahokomb"; 8 - nasoseptal vascularized mucoperichondrial flap; 9 - common nasal passage; 10 - middle nasal concha.

The method is as follows.

Endonasal interventions are performed using the Karl Stortz endoscopic stand and 0 °, 45 ° and 70 ° optics under endotracheal anesthesia. The use of this optics allows you to optimally visualize the lateral sections of the sphenoid sinus.

To achieve maximum vasoconstriction, turundas are injected into the nasal cavity moistened with 10% lidocaine solution with drops of adrenaline.

Then mucoperichondria and mucoperiostasis of the nasal septum are hydrotreated on both sides, a hemitransfection incision is performed in anticipation of the nose on the left, and mucoperichondria and mucoperiostis are separated on both sides. Then they mobilize a quadrangular cartilage of the “swinging door” type, resect the bone section of the nasal septum, and isolate rostrum sphenoidale.

Using the bone bite, the anterior wall of the sphenoid sinus 1 is opened. Thus, a transeptal approach to the sphenoid sinus is carried out (Fig. 1).

Deepithelialization of the cavity of the sphenoid sinus is performed.

The presence of a wide trepanation hole 2 in the central part of the anterior wall 1 of the sphenoid sinus, the use of endoscopes with different optical angles allows you to carefully examine all sections of the sphenoid sinus and reliably visualize the cerebrospinal fluid fistula 3, as well as freely manipulate the lumen of the sphenoid sinus 2 (Fig. 2).

In the presence of meningoencephalocele 4 in the lumen of the sinus 2, coagulation of the meninges within the cerebrospinal fluid fistula 3 is performed using a monopolar electrocoagulator (Fig. 3).

Then, a free autograft 5 corresponding to the size of the cerebrospinal fluid fistula 3 is cut out from the quadrangular cartilage of the nasal septum.

A free autograft 5 from a quadrangular cartilage is led extradurally beyond the edges of the cerebrospinal fistula 3.

A free autograft 5 from a quadrangular cartilage is fixed using the Tissucol two-component fibrothrombin glue 6. A Tachocomb 7 sponge is placed on top of a free autograft 5 from a quadrangular cartilage, 3-5 mm larger than the diameter of the liquor fistula 3 (Fig. 4).

Next, a nasoseptal vascularized mucoperichondrial flap 8 containing the posterior septal artery is cut out. The mucous membrane is cut using a monopolar electrocoagulator, it starts in the projection of the sphenoid-palatal opening, passes along the front wall of the 1 sphenoid sinus along the vault of the choana with the transition to the mucous membrane of the nasal septum in its lower sections and continues parallel to the bottom of the nasal cavity.

Then they pass into a vertical section and horizontally parallel to the arch of the nasal cavity along the mucous membrane of the nasal septum and return to the posterior sections of the nasal septum with a transition to the anterior wall of the 1 sphenoid sinus below the natural anastomosis.

The size of the nasoseptal vascularized mucoperichondrial flap 8 in this case depends on the location and size of the cerebrospinal fistula 3 in the sphenoid sinus.

The previously performed transeptal access to the sphenoid sinus allows unhindered manipulations in the nasal cavity (upper sections of the common nasal passage 9, sphenoethmoid pocket) without additional interventions on the middle 10 and upper nasal concha (Fig. 5).

The selected nasoseptal vascularized mucoperichondrial flap 8 is placed in the lumen of the sphenoid sinus 2 in the area of the cerebrospinal fluid fistula 3. Using a raspator, the nasoseptal vascularized mucoperichondrial flap 8 is spread in the lumen of the sphenoid sinus 2, tightly pressed against the bone walls. Then perform tamponade of the lumen of the sphenoid sinus 2 collagen hemostatic sponge (Fig. 6). The operation is completed with anterior tamponade for 2 days.

For 7 days install extended lumbar drainage.

The method is illustrated by the following examples.

Example 1. Patient I., born in 1939 arrived at the I neurosurgical department of the Russian National Research Institute of Nuclear Medicine. prof. A.L. Polenova with complaints of transparent discharge mainly from the left half of the nose, aggravated by tilting the head forward, periodically occurring headache in the occipital-parietal region, aggravating in the vertical position of the body, the patient associates the headache with the appearance of discharge from the nasal cavity.

From the anamnesis it is known: he considers himself a patient for about 2 years, when there were complaints of discharge from the nasal cavity, a feeling of mucus running down the back of the throat, and a headache. She was treated in a community clinic with a diagnosis of vasomotor rhinitis. Brain injury denied.

CT-cisternography was performed - a defect in the bone of the lateral wall of the sphenoid sinus on the left with a diameter of 5 mm with the flow of cerebrospinal fluid to the left half of the sphenoid sinus, concha bullosa on the right, curvature of the nasal septum to the left. Biochemical analysis of discharge from the nasal cavity: according to the biochemical composition (glucose and protein content), discharge from the nasal cavity corresponded to cerebrospinal fluid. The daily volume of discharge from the nasal cavity was ≈15 ml.

Surgical intervention was performed - endonasal plastic surgery of the cerebrospinal fluid fistula with a nasoseptal vascularized mucoperichondrial flap under endovideoscopic control.

Intervention was performed using the Karl Stortz endoscopic stand and 0 °, 45 ° optics under endotracheal anesthesia.

Turunds moistened with 10% lidocaine solution with drops of adrenaline were introduced into the nasal cavity.

Hydrotreating of mucoperichondria and mucoperiostasis of the nasal septum on both sides was performed, a hemitransfection incision was made in anticipation of the nose on the left, mucoperichondria and mucoperiostasis were separated on both sides, the quadrangular cartilage of the swinging door type was mobilized, the bony spine of the rodent septum was partially resected. With the help of bone biting machines, the anterior wall of the sphenoid sinus is opened.

Performed epithelialization of the cavity of the sphenoid sinus. A 7 × 10 mm bone defect is visualized in the sinus lumen on the lateral wall on the left, with meningoencephalocele proliferating through it into the sinus lumen. Coagulation of meninges within a bone defect was performed using a monopolar electrocoagulator.

An autograft corresponding to the size of the liquor fistula of the sphenoid sinus is cut from the quadrangular cartilage of the nasal septum of the nose. This autograft is placed on a bone defect and fixed using the Tissucol two-component fibrintrombin glue. On top of this autograft, a Tachocomb sponge has been placed.

Next, a nasoseptal vascularized mucoperichondrial flap was cut using a monopolar electric knife, which was subsequently placed into the lumen of the sphenoid sinus in the area of the cerebrospinal fluid fistula. Using a raspator, the flap was straightened in the lumen of the sinus and tightly pressed against the bone walls, followed by tamponade of the lumen of the sinus with a collagen hemostatic sponge.

The operation ended with anterior tamponade for 2 days and installation for 7 days of extended lumbar drainage.

Example 2. Patient G., born in 1947 entered the II neurosurgical department of the Russian National Research Institute of Nuclear Medicine. prof. A.L. Polenova with complaints of transparent discharge mainly from the left half of the nose, headache.

From the anamnesis it is known: he considers himself sick for about 6 months, when there were complaints of discharge from the nasal cavity, a feeling of draining mucus along the back of the throat, and a headache. He had purulent meningitis twice.

An MRI of the brain was performed - a deep lateral pocket of the sphenoid sinus with a bone defect in its lateral sections, prolapse of the meninges into the lumen of the sinus with the expiration of cerebrospinal fluid in the left half of the sphenoid sinus is determined.

Surgical intervention was performed - endonasal plastic surgery of the cerebrospinal fluid fistula with a nasoseptal vascularized flap under endovideoscopic control.

Intervention was performed using the Karl Stortz endoscopic stand and 0 °, 45 ° optics under endotracheal anesthesia.

Turunds moistened with 10% lidocaine solution with drops of adrenaline were introduced into the nasal cavity.

The mucoperichondria and mucoperiostasis of the nasal septum on both sides were hydrotreated, a hemitransfection incision was made in anticipation of the nose on the left, mucoperichondria and mucoperiostasis were separated on both sides, quadrangular cartilage of the “swinging door” type was mobilized, the osseous part of the rodent septum was partially resected. With the help of bone biting machines, the anterior wall of the sphenoid sinus is opened.

Performed epithelialization of the cavity of the left half of the sphenoid sinus. A deep pocket is visualized in the sinus lumen on the lateral wall on the left with the presence of a bone defect of 2 × 5 mm in its lateral parts, with meningoencephalocele proliferating through it into the sinus lumen. Coagulation of the meninges within the cerebrospinal fluid fistula was performed using a monopolar electrocoagulator.

An autograft of a quadrangular cartilage is placed on a bone defect, fixed and sealed with fibrothrombin glue, a Tachocomb sponge is placed on top and fixed with a Tissucol two-component fibrothrombin glue.

Next, a nasoseptal vascularized mucoperichondrial flap was cut using a monopolar electric knife, which was placed in the lumen of the sphenoid sinus in the area of the cerebrospinal fluid fistula. Using a raspator, the flap was straightened in the lumen of the sinus and tightly pressed against the bone walls, followed by tamponade of the lumen of the sinus with a collagen hemostatic sponge.

The operation ended with anterior tamponade for 2 days and installation for 7 days of extended lumbar drainage.

The advantages of the proposed method are:

- the reliability of the plastic cerebrospinal fluid fistula of the lateral wall of the sphenoid sinus;

- the convenience of forming a nasoseptal vascularized mucoperichondrial flap;

- the ability to freely manipulate in the surgical field without additional intervention.

Claims (2)

1. A method for plasty of bone defects in the base of the skull accompanied by nasal lymphorrhea, including access to the sphenoid sinus using an endovideoscopic technique, cerebrospinal fluid fistula performed sequentially first with a free autograft and then with a nasoseptic vascularized mucoperichondrial flap on the nasal vascular pedicle, fixation of the indicated flap and lumbar drainage, characterized in that they produce transeptal access to the sphenoid sinus, as a free graft is used moiety quadrangular cartilage that give birth to the edges CSF fistulae extradurally, fixed with fibrin glue, and on top of the free autograft laid sponge "Tachocomb", while nazoseptalny vascularized mukoperihondrialny flap formed before grafting CSF fistulae. 2. The method of plasticizing bone defects of the base of the skull according to claim 1, characterized in that the fixation of the indicated flap is carried out by tamponade of the lumen of the sphenoid sinus with a collagen hemostatic sponge.

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