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Endoscopic Sinus Views Video
Endoscopic Sinus Surgery Endoscopic Resection of Fronto-ethmoid Meningoencephalocele & Repair of Skull Base Defect
The following case illustrates the effectiveness and minimally invasive nature of the endoscopic approach for an anterior skull base defect. The patient is a 35 year old male referred by another otolaryngologist for evaluation of a large right-sided nasal mass. He had several months of right sided nasal airway obstruction. In the months preceding presentation to Arizona Sinus Center he developed seizures and was hospitalized for bacterial meningitis. A CT scan revealed a large right nasal cavity soft-tissue mass and opacification of the right maxillary, ethmoid and frontal sinuses. A 2 cm dehiscence of the posterior table of the frontal sinus and ethmoid roof was present just anterior to the anterior ethmoid artery. An MRI of the brain revealed a large meningoencephalocele protruding through the skull base and filling the anterior ethmoid and nasal cavities. Post-obstructive maxillary and frontal sinusitis was also present. Given the history of recent bacterial meningitis, the patient was presumed to have a small CSF leak from the large meningoencephalocele within the ethmoid or nasal cavity. Removal of the meningoencephalocele sack containing infarcted brain tissue and repair of the bony and soft tissue skull base defect is necessary to prevent future episodes of intracranial infection. The procedure was performed with 30 degree and 70 degree telescopes. The first stage of the procedure involves resecting the meningoencephalocele up to the defect in the skull base, adjacent to the orbital gyri of the brain. A microdebrider is utilized for this. Bipolar cautery and judicious monopolar suction cautery are used to ablate and cauterize the proximal portion of the meningoencephalocele. The mucosa surrounding the boney defect on the posterior table of the frontal sinus and the anterior ethmoid roof are excised and ablated to provide exposed skull base bone which will receive the soft tissue graft well. Utilizing a 70 degree telescope, a frontal sinusotomy is performed to prevent a post-operative frontal mucocele. A septal bone graft is harvested through a mucoperichondrial incision on the left side of the septum. A free mucosal graft is obtained from the left inferior turbinate. The septal bone graft is placed in the bony defect on the skull base. The mucosal graft is then placed inferior to that. Biocompatible tissue glue is placed to seal the graft to the skull base. A rolled silicone sheet stent is placed to support the graft and prevent post-operative frontal recess stenosis. The ethmoid cavity is lightly packed with dissolvable material. One week post-operatively the nasal and ethmoid cavity is lightly debrided in the office. The patient irrigated his nose twice daily with saline solution starting one week post-operatively. The patient was evaluated in the office every two weeks until the sinus mucosa was completely healed. Five months post-operatively the patient has remained free of meningitis and seizures.
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Endoscopic Sinus Surgery
