Endoscopic Repair of Skull Base Fracture

welcome to ENT Discovery today we are
going to present the case of CSF rhinnorhea due to fracture at the skull base
and as you can see the fracture is just medial to the attachment of the superior
turbinate this is the first step it’s on the left side we infiltrate the inferior
turbinate to reduce its size and infiltrate also the area of the uncinate
process mucosa we use one in two hundred thousand ………
infusion on infiltration the first step is to perform uncinectomy and we start
from the lower half of the uncinate using the sickle knife we just go medial
to the attachment of the uncinate to the lateral nasal wall we can
complete the procedure of uncinectomy using the shaver or microdebrider
it’s one of the true cut cutting instruments so we don’t have any mucosal
tears it’s a true cutting instrument as you can see this is the uncinate process
part of it is left as a landmark most of it is removed using the microdebrider lifting the middle turbinate just medial as you can see this is the
bullae just in front of you this is the bullae we try to remove part of it the safest
way is to to remove it or excise it inferiomedially because in this way we
avoid trauma to the lamina propria we prefer to use the microdebrider
as a true cutting instrument to remove the medial part of the Bullae and also
we leave the lateral part as a landmark so we have two planes the uncinate as
well as the the other plane just deeper is the plane of the bulla this is the
area of the axilla of the middle turbinate and you can see the ground lamina or
basal lamella immediately in front of us this case the patient has no retrobullar recess where removal of the anterior wall of the bulla will expose
the ground lamella or basal lamella it’s a common finding we don’t have a
posterior wall of the bulla in this case this procedure is known as anterior ethmoidectomy where we’ll move the bulla and identify or expose the ground lamella
or basal lamella in this case or in this step we are removing part of the basal
lamella and for safety we start inferio medially just like the bulla because we
avoid trauma to the lamina laterally and inferiorly because we
avoid trauma or injury to the skull base so the safest way to penetrate or
remove or excise the bulla as well as the ground lamella or basal lamella inferiomedially by this way we will go to the posterior ethmoidal air cells just behind the ground lamella appears
the superior turbinate just behind the ground lamella between the superior turbinate and the
septum as you can see this is the natural osteum of the sphenoid sinus
it’s very obvious that the CSF leak from above that area is straggling basal
lamella again ground lamella being grilled using the microdebrider safely
cautiously remember that the ground lamella is also attached to the lamina
propria so we have to remove it inferiomedially while
doing so we are exposing the superior turbinate very obvious in the middle of
the screen to the lateral we have the ethmoid and to the medial we have the
sphenoethmoidal recess area in this case it’s a very interesting
because we don’t have pathology in mucosa of the nose and sinuses so it’s
very nice to see the natural Anatomy without following the mucosa edema or
polyps or debris superior turbinate again being pushed
laterally exposing the natural osteum of the sphenoid sinus on the left side and
above it we can see the pulsations and CSF leak above the sphenoid sinus
osteum and this is the area of the sphenoethmoidal recess this is a post-traumatic case she
developed CSF rhinorrhea following trauma for two months with no
improvement upon conservative management this is the sphenoid sinus osteum again
we are pushing the superior turbinate just laterally superior turbinate to expose the
area of the defect at the roof of the sphenoethmoidal recess area this
is the site of the leak the mucosal tear very obvious in the roof of the sphenoethmoidal recess area fillings of the mucosa with the CSF and then it it leaks
just acting like a wall you can see the pulsations of CSF very obvious in this
case we didn’t use intrathecal fluroscene as CSF leak with mucosal tear at the roof
of the sphenoethmoidal recess area these are the air bubbles reappears we
have to refresh the edges of the leak or tear before placement of the graft in this case we harvested septal
cartilage the leak is on the left side and we use the right mucosal or right
side of the septum for harvesting our septal cartilage we made the incision on
the right side this will make the field on the left side free of blood we
elevated the mucoperichondrium flap and this is the cartilage proper front of us
being incised we use a scalpel 11 size 11 and this is a minimally invasive
septal cartilage harvesting we use the endoscope and this can be part of
septoplasty procedure in this case we made the C shape incision one limb
anteriorly and the other limb inferiorly this is the cartilage proper being
elevated from the contralateral mucoperichondrium and the cost is being in sized circumferentially and lift it off the
mucoperichondrium from the left side very gently not to make a tear in the
mucosa of the cartilage and take it and harvest it and we try to apply it at the site of
the leak where we have mucosal tear as well as bony defect because it being placed at the area of
the defect we try to apply it in an underlay manner beneath the mucosal tear very gently applying it and we have to
make sure after application of the cartilage that there is no leak and
usually we perform what’s known as positive pressure ventilation to raise
the inter-cranial pressure and make sure that our graft or cartilage stopped the
leak completely otherwise we can manipulate until we seal off the defect
where there is no CSF rhinnorrhea or leak when performing the positive pressure
ventilation after placement of the cartilage at the
area of the defect then we applied piece of fat on top of that between the superior
turbinate the cartilage the superior turbinate laterally and the piece of
cartilage or area of the leak medially then we apply fascia latta graft you
can see and on top of these we apply gel foam
all these to support the graft so we have multi layer we have septal
cartilage fat fascia latta and top of these we apply gel foam to support a
graft fortunately this operation was done
eight months ago and the patient did not complain of any CSF leak thank you

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