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An Effective Method of Frontal Sinus Reconstruction After Bifrontal Craniotomy: Experience with 103 Patients Satoru Takeuchi1,2, Rokuya Tanikawa2, Makoto Katsuno3, Toshiyuki Tsuboi2, Kosumo Noda2, Junpei Oda2, Shiro Miyata2, Nakao Ota2, Hiroyasu Kamiyama2
BACKGROUND: Bifrontal craniotomy is effective for the treatment of anterior skull base lesions. However, the frontal sinus (FS) is often opened during this surgery, and various postoperative complications may occur as a result of the open FS, including cerebrospinal fluid leakage and infection. We describe our procedure for maintaining the patency of the nasofrontal duct and direct suture of the exposed and violated FS mucosa.
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METHODS: Bifrontal craniotomy with reconstruction of the FS was performed in 103 patients (68 women and 35 men; age range, 32e90 years; mean age, 62.6 years) for lesions including anterior cerebral artery aneurysm (100 cases), arteriovenous fistula (1 case), and meningioma (2 cases). After opening the FS, the mucosal membrane of the FS was dissected from the FS wall, and the orifice of the FS mucosa was closed with 7-0 monofilament running sutures. The nasofrontal duct was kept open by washing thoroughly to remove any bone dust and clot in the FS. The cavity of the FS was then packed with abdominal fat.
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RESULTS: Postoperative cerebrospinal fluid leakage and mucocele formation did not occur in any patient. An intracranial infectious complication occurred in 1 patient (1.0%).
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CONCLUSIONS: The present results indicate the effectiveness of our technique for the prevention of FS-related postoperative complications.
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Key words Bifrontal craniotomy - Cerebrospinal fluid - Complication - Frontal sinus - Infection -
Abbreviations and Acronyms CSF: Cerebrospinal fluid FS: Frontal sinus NFD: Nasofrontal duct
WORLD NEUROSURGERY 83 [6]: 907-911, JUNE 2015
INTRODUCTION
B
ifrontal craniotomy is effective for the treatment of anterior skull base tumors (5, 6, 16, 18) and anterior cerebral artery aneurysms (1, 4, 13, 18, 21, 32). However, the frontal sinus (FS) is often opened during this surgery, and various postoperative complications may occur as a result of the open FS, including cerebrospinal fluid (CSF) leakage and infection (e.g., meningitis, brain abscess, subdural abscess, epidural abscess, and subcutaneous or subperiosteal abscess) (5, 8, 10, 17, 18, 20, 22, 25, 26, 32). The mucosa of the FS tends to form mucocele, especially if the nasofrontal duct (NFD) is obstructed. Such FS mucoceles have a slow and insidious tendency to enlarge, resulting in late-onset infection in some cases (29). Various methods have been employed for reconstruction of the anterior skull base, including cranialization and obliteration of the FS (3, 11, 16, 23, 24, 30). Cranialization involves elimination of the posterior wall of the FS, meticulous removal or coagulation of the FS mucosa, and allowing the frontal lobe to rest against the anterior table and floor of the FS (11). Obliteration involves permanent occlusion of the frontal recess and physical obliteration of the FS (11). Numerous methods for obliteration of the FS have been reported, including the use of fat, fascia, muscle, galeal or pericranial flap, bone, and titanium plates (2-4, 6, 8, 11, 16, 23-25, 30). However, CSF leakage and infection are major postoperative problems, with reported frequencies of 2%e20% and 3%e20%, respectively (5, 8, 10, 17, 18, 20, 22, 25, 26, 32). More effective methods for FS reconstruction are needed to decrease the complication rate. For many years, we have used a surgical technique based on direct suture of the exposed and violated FS mucosa because it is important to leave the NFD open and to seal the FS mucosa completely. However, this technique has rarely been reported and discussed (19). In the present study, we describe in detail
From the 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama; 2Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido; and 3 Department of Neurosurgery, Abashiri Neurosurgical and Rehabilitation Hospital, Abashiri, Hokkaido, Japan To whom correspondence should be addressed: Satoru Takeuchi, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 6:907-911. http://dx.doi.org/10.1016/j.wneu.2015.01.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
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FORUM SATORU TAKEUCHI ET AL.
FRONTAL SINUS RECONSTRUCTION AFTER BIFRONTAL CRANIOTOMY
our procedure for treating the exposed FS during bifrontal craniotomy and discuss the results and outcomes of our procedure.
MATERIALS AND METHODS This study was conducted with the approval of the ethics committee of the National Defense Medical College. The committee concluded that written informed consent was not required because of the retrospective nature of the investigation. This study included 103 patients (68 women and 35 men; age range, 32e90 years; mean age, 62.6 years) who underwent bifrontal craniotomy with FS exposure and mucosal violation for frontal base lesions, including anterior cerebral artery aneurysm (22 ruptured and 78 unruptured cases), arteriovenous fistula (1 case), and meningioma (2 cases), between November 2010 and May 2014 at 2 hospitals (Teishinkai Hospital and Abashiri Neurosurgical and Rehabilitation Hospital). In all 103 patients, FS reconstruction was performed using direct suture of the exposed and violated FS mucosa as described subsequently. Retrospective chart review was used to collect demographic data, including age, sex, indication for surgery, presence of postoperative complication (CSF leakage, infection, and mucocele formation), and follow-up findings. Surgical Technique of Bifrontal Craniotomy The patient was placed in the supine position. The head was placed slightly above the level of the heart. A bicoronal skin incision that covered the forehead was made behind the hairline (Figure 1A). The skin flap was separated from the periosteum with the subgaleal connective tissue. After incision and elevation of the periosteum, 2 or 3 burr holes were made in the frontal region depending on the size of the FS, and craniotomy was performed in a temple bell shape (Figure 1B). The medial-inferior craniotomy margin was the root of the nose. The FS was exposed in most cases (21).
Surgical Technique of FS Reconstruction After opening the FS (Figure 2A), the posterior wall of the FS was eliminated, and the mucosal membrane of the FS was dissected from the FS wall. Hemostasis against refractory bleeding from the FS wall was performed using monopolar coagulation. The NFD was kept open by washing thoroughly to prevent retention of any bone dust and clot in the FS using an irrigation and suction system (Ohwa Tsusho Co., Ltd., Tokyo, Japan) developed by Kamiyama et al. (14) (Figure 2B). The margin of the orifice of the FS mucosa was stained with pyoktanin blue to improve visualization and was closed with 7-0 monofilament running sutures (Figure 2C and D). Absorbable gelatin sponge (Gelfoam; Pfeizer Inc., NY, USA) soaked in fibrin glue was attached to the sutured area (Figure 2E). The cavity of the FS was packed with abdominal fat mixed with fibrin glue (Figure 2F). After complete dural closure, the bone flap was returned to the skull. The periosteum, subcutaneous tissue, and skin were closed in layers (21). Postoperative Management Antibiotics (cefazolin 2 g/day) were administered for 2 days. The patients were required to avoid sneezing for 3 months. CSF leakage was defined as persistent postoperative leakage of a glucose-containing serous liquid from the nasal cavities. Patients with postoperative meningeal signs or high fever were required to undergo CSF examination and magnetic resonance imaging or computed tomography or both to detect the presence of meningitis, brain abscess, subdural abscess, epidural abscess, or subcutaneous or subperiosteal abscess. Magnetic resonance imaging or computed tomography was routinely performed 3 months after surgery and annually thereafter to detect such complications. RESULTS The follow-up period was 3e45 months (mean, 16 months). Postoperative CSF leakage and mucocele formation did not occur in any patient. An intracranial infectious complication occurred in
Figure 1. Intraoperative photographs of the interhemispheric approach. The patient was placed in the supine position. The head was placed slightly above the level of the heart. A bicoronal skin incision covering the forehead was made behind the hairline (A). The craniotomy was performed in a temple bell shape after incision and elevation of the periosteum (B).
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Figure 2. Intraoperative photographs of frontal sinus (FS) reconstruction. After opening the FS (A), the posterior wall of the FS was eliminated, and the mucosal membrane of the FS was dissected from the FS wall. The nasofrontal duct was kept open by washing thoroughly using an irrigation and suction system (B). The margin of the orifice of the FS mucosa was
1 patient, a 59-year-old man with a past history of diabetes mellitus. He underwent clipping for an unruptured distal anterior cerebral artery aneurysm via bifrontal craniotomy. The FS was exposed and reconstructed as described previously. After surgery, he was asked to avoid sneezing, but he sneezed frequently. He experienced a fever 2 months after surgery, and an epidural abscess was diagnosed. He underwent removal of the bone flap. He underwent cranioplasty 6 months later. He was healthy with no neurologic deficit 21 months after the first surgery. DISCUSSION CSF leakage as a complication of open FS after bifrontal craniotomy rarely resolves spontaneously and can cause infectious complications or pneumocephalus, and additional surgery or spinal CSF drainage is often required (6, 9, 27, 28). In addition, infectious complications can result from the formation of mucocele (29). These complications can lead to postoperative worsening and extended hospitalization. Several materials for obliteration of the FS are available (2-4, 6, 8, 11, 16, 23-25, 30); we used abdominal fat with fibrin glue (3, 23, 30) because we believe that use of artificial materials should be avoided, and the volume of fat is easy to adjust to the size of the FS defect. However, obliteration with fat only can prevent a dead space but cannot prevent the formation of mucocele and subsequent infection (30). The frequencies of mucocele development and infection after obliteration with fat only are approximately 10% and 3%, respectively. We believe that fat obliteration should be combined with methods to prevent mucocele formation.
WORLD NEUROSURGERY 83 [6]: 907-911, JUNE 2015
FRONTAL SINUS RECONSTRUCTION AFTER BIFRONTAL CRANIOTOMY
stained with pyoktanin blue to improve visualization and was closed with 7-0 monofilament running sutures (C and D). Gelfoam sponge soaked in fibrin glue was attached to the sutured area (E). The cavity of the FS was packed with abdominal fat mixed with fibrin glue (F).
Generally, the FS mucosa is stripped away or coagulated regardless of the method of obliteration (7, 8, 30). This procedure may prevent some CSF leakage, but mucocele may be formed by obstruction of the NFD, resulting in late-onset infection. Our methods for maintaining the patency of the NFD and direct suture of the exposed and violated FS mucosa are more reliable to prevent the formation of mucocele and seal the FS mucosa completely compared with removal or coagulation of the FS. The present study to our knowledge is the largest series to date to report direct suture of the exposed and violated FS mucosa for FS reconstruction. Previously, 51 consecutive patients underwent bifrontal craniotomy with exposed and violated FS (19). The surgical technique included direct suture of the exposed and violated FS mucosa with pericranial flap, and none of the 51 patients developed postoperative CSF leakage or meningitis (19). In the present study, the frequencies of CSF leakage and infectious complications were 0% and 1.0%, respectively, which are significantly lower than frequencies previously reported. We think that past history of diabetes mellitus and frequent sneezing might have contributed to the development of a postoperative infectious complication in the 1 affected patient. It is well known that approximately 3 months is required for complete epithelialization of the wounded paranasal sinuses (12, 31), so we recommended that sneezing should be avoided during this period. The previous and the present findings indicate that direct suture of the exposed and violated FS mucosa results in reduced risks of postoperative CSF leakage and infectious complications. We think that maintaining the patency of the NFD is the most important factor to prevent the formation of mucocele, which causes lateonset infection. The irrigation and suction system, which we have
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FRONTAL SINUS RECONSTRUCTION AFTER BIFRONTAL CRANIOTOMY
routinely used to maintain the clean operative field for many years (14), was quite useful to remove bone dust and clot in the NFD, resulting in maintaining the patency of the NFD. In addition to the above-mentioned advantage, we consider that direct suture of the mucosa has some further merits. First, direct suture under the operating microscope is a very useful practice for young neurosurgeons to improve their microsurgical suturing skills (15). Laboratory training may be essential to gain microneurosurgical experience, but the relaxed and static environment is not comparable to that of the operating room, where the stress of actual surgery imposes entirely different demands on the surgeon (15). Our policy is consistent with such an approach to training. Second, this method does not require spinal CSF drainage, so drainage-related complications, including low intracranial pressure, intracranial hematoma, and infection, can be avoided (19).
REFERENCES 1. Chhabra R, Gupta SK, Mohindra S, Mukherjee K, Bapuraj R, Khandelwal N, Khosla VK: Distal anterior cerebral artery aneurysms: bifrontal basal anterior interhemispheric approach. Surg Neurol 64:315-319, 2005. 2. Costa H, Cerejo A, Baptista A, Vaz R, Gonçalves M, Guimarães A: The galea frontalis myofascial flap in anterior fossa CSF leaks. Br J Plast Surg 46:503-507, 1993. 3. Donald PJ, Ettin M: The safety of frontal sinus fat obliteration when sinus walls are missing. Laryngoscope 96:190-193, 1986. 4. El-Noamany H, Nakagawa F, Hongo K, Kakizawa Y, Kobayashi S: Low anterior interhemispheric approach—a narrow corridor to aneurysms of the anterior communicating artery. Acta Neurochir 143:885-891, 2001. 5. Feiz-Erfan I, Han PP, Spetzler RF, Horn EM, Klopfenstein JD, Kim LJ, Porter RW, Beals SP, Lettieri SC, Joganic EF: Preserving olfactory function in anterior craniofacial surgery through cribriform plate osteotomy applied in selected patients. Neurosurgery 57 (1 Suppl):86-93, 2005. 6. Fliss DM, Gil Z, Spektor S, Leider-Trejo L, Abergel A, Khafif A, Amir A, Gur E, Cohen JT: Skull base reconstruction after anterior subcranial tumor resection. Neurosurg Focus 12:e10, 2002.
The present study has some limitations. We evaluated the state of the NFD only by intraoperative microscopic observation, and we could not assess accurately the patency of the NFD. Further studies using fiberoptic transillumination may be required to investigate whether our methods can maintain complete patency of the NFD. In addition, we failed to investigate the usefulness of our methods statistically because of the lack of an appropriate comparison group. Further studies are also necessary on this point. CONCLUSIONS Maintenance of the patency of the NFD and direct suture of the exposed and violated FS mucosa with fat obliteration is a reliable and effective method to prevent postoperative complications after opening of the FS.
vascularized outer table calvarial bone graft. Neurosurgery 36:725-731, 1995. 11. Horowitz G, Amit M, Ben-Ari O, Gil Z, Abergel A, Margalit N, Cavel O, Wasserzug O, Fliss DM: Cranialization of the frontal sinus for secondary mucocele prevention following open surgery for benign frontal lesions. PLoS One 8:e83820, 2013. 12. Hosemann W, Wigand ME, Göde U, Länger F, Dunker I: Normal wound healing of the paranasal sinuses: clinical and experimental investigations. Eur Arch Otorhinolaryngol 248:390-394, 1991. 13. Ito S, Fujimoto S, Saito K, Tada H, Tanaka T: Postoperative olfactory dysfunction in interhemispheric approach for ruptured anterior communicating artery aneurysms [in Japanese]. No Shinkei Geka 24:625-628, 1996. 14. Kamiyama H, Abe H, Nomura M, Saito H, Yasui N: Acute stage operations for cerebral aneurysms, intracerebral hematomas, arterio-venous malformation high pressure irrigation and suction system [in Japanese]. Surg Cereb Stroke 16: 282-286, 1988. 15. Kivelev J, Hernesniemi J: Four-fold benefit of wound closure under high magnification. Surg Neurol Int 4:115, 2013. 16. Kryzanski JT, Annino DJ Jr, Heilman CB: Complication avoidance in the treatment of malignant tumors of the skull base. Neurosurg Focus 12:e11, 2002.
Tamakawa N, Moroi J, Suzuki A, Yasui N: CSF leakage and anosmia in aneurysm clipping of anterior communicating artery by basal interhemispheric approach [in Japanese]. No Shinkei Geka 39:263-268, 2011. 21. Noda K, Tanikawa R, Kamiyama H, Ohta N, Yabuuchi T, Miyata S, Kosaka A, Tsuboi T, Tokuda S: Interhemispheric approach for Acom aneurysm [in Japanese]. Jpn J Neurosurg 21: 834-841, 2012. 22. Schramm VL Jr, Maroon JC: Sinus complications of frontal craniotomy. Laryngoscope 89:1436-1445, 1979. 23. Sessions RB, Alford BR, Stratton C, Ainsworth JZ, Shill O: Current concepts of frontal sinus surgery: an appraisal of the osteoplastic flap-fat obliteration operation. Laryngoscope 82:918-930, 1972. 24. Sinha UK, Johnson TE, Crockett D, Vadapalli S, Gruen P: Three-layer reconstruction for large defects of the anterior skull base. Laryngoscope 112:424-427, 2002. 25. Siniscalchi EN, Angileri FF, Mastellone P, Catalfamo L, Giusa M, Conti A, De Ponte FS, Tomasello F: Anterior skull base reconstruction with a galeal-pericranial flap. J Craniofac Surg 18: 622-625, 2007. 26. Tosun F, Gonul E, Yetiser S, Gerek M: Analysis of different surgical approaches for the treatment of cerebrospinal fluid rhinorrhea. Minim Invasive Neurosurg 48:355-360, 2005.
7. Fujiwara H, Yasui N, Nathal-Vera E, Suzuki A: Anosmia after anterior communicating artery aneurysm surgery: comparison between the anterior interhemispheric and basal interhemispheric approaches. Neurosurgery 38:325-328, 1996.
17. Kryzanski JT, Annino DJ, Gopal H, Heilman CB: Low complication rates of cranial and craniofacial approaches to midline anterior skull base lesions. Skull Base 18:229-241, 2008.
8. Goel A: Multilayer reconstruction of the anterior cranial fossa floor. Br J Neurosurg 12:254-258, 1998.
18. Meetze K, Palmer JN, Schlosser RJ: Frontal sinus complications after frontal craniotomy. Laryngoscope 114:945-948, 2004.
27. Tuettenberg J, Czabanka M, Horn P, Woitzik J, Barth M, Thomé C, Vajkoczy P, Schmiedek P, Muench E: Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure. J Neurosurg 110:1200-1208, 2009.
9. Guppy KH, Silverthorn JW, Akins PT: Subarachnoid hemorrhage due to retained lumbar drain. J Neurosurg Spine 15:641-644, 2011.
19. Murai Y, Mizunari T, Kobayashi S, Teramoto A: Surgical technique for the prevention of cerebrospinal fluid leakage after bifrontal craniotomy. World Neurosurg 81:344-347, 2014.
28. Van Velthoven V, Clarici G, Auer LM: Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery. Acta Neurochir 109:26-29, 1991.
20. Nakayama H, Ishikawa T, Yamashita S, Fukui I, Mutoh T, Hikichi K, Yoshioka S, Kawai H,
29. Wallis A, Donald PJ: Frontal sinus fractures: a review of 72 cases. Laryngoscope 98:593-598, 1988.
10. Hasegawa M, Torii S, Fukuta K, Saito K: Reconstruction of the anterior cranial base with the galeal frontalis myofascial flap and the
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FRONTAL SINUS RECONSTRUCTION AFTER BIFRONTAL CRANIOTOMY
30. Weber R, Draf W, Keerl R, Kahle G, Schinzel S, Thomann S, Lawson W: Osteoplastic frontal sinus surgery with fat obliteration: technique and longterm results using magnetic resonance imaging in 82 operations. Laryngoscope 110:1037-1044, 2000. 31. Xu G, Jiang H, Li H, Shi J, Chen H: Stages of nasal mucosal transitional course after functional
endoscopic sinus surgery and their clinical indications. ORL J Otorhinolaryngol Relat Spec 70: 118-123, 2008. 32. Yasui N, Nathal E, Fujiwara H, Suzuki A: The basal interhemispheric approach for acute anterior communicating aneurysms. Acta Neurochir 118:91-97, 1992.
Citation: World Neurosurg. (2015) 83, 6:907-911. http://dx.doi.org/10.1016/j.wneu.2015.01.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
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911
An Effective Method of Frontal Sinus Reconstruction After Bifrontal Craniotomy: Experience with 103 Patients Satoru Takeuchi1,2, Rokuya Tanikawa2, Makoto Katsuno3, Toshiyuki Tsuboi2, Kosumo Noda2, Junpei Oda2, Shiro Miyata2, Nakao Ota2, Hiroyasu Kamiyama2
BACKGROUND: Bifrontal craniotomy is effective for the treatment of anterior skull base lesions. However, the frontal sinus (FS) is often opened during this surgery, and various postoperative complications may occur as a result of the open FS, including cerebrospinal fluid leakage and infection. We describe our procedure for maintaining the patency of the nasofrontal duct and direct suture of the exposed and violated FS mucosa.
-
METHODS: Bifrontal craniotomy with reconstruction of the FS was performed in 103 patients (68 women and 35 men; age range, 32e90 years; mean age, 62.6 years) for lesions including anterior cerebral artery aneurysm (100 cases), arteriovenous fistula (1 case), and meningioma (2 cases). After opening the FS, the mucosal membrane of the FS was dissected from the FS wall, and the orifice of the FS mucosa was closed with 7-0 monofilament running sutures. The nasofrontal duct was kept open by washing thoroughly to remove any bone dust and clot in the FS. The cavity of the FS was then packed with abdominal fat.
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RESULTS: Postoperative cerebrospinal fluid leakage and mucocele formation did not occur in any patient. An intracranial infectious complication occurred in 1 patient (1.0%).
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CONCLUSIONS: The present results indicate the effectiveness of our technique for the prevention of FS-related postoperative complications.
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Key words Bifrontal craniotomy - Cerebrospinal fluid - Complication - Frontal sinus - Infection -
Abbreviations and Acronyms CSF: Cerebrospinal fluid FS: Frontal sinus NFD: Nasofrontal duct
WORLD NEUROSURGERY 83 [6]: 907-911, JUNE 2015
INTRODUCTION
B
ifrontal craniotomy is effective for the treatment of anterior skull base tumors (5, 6, 16, 18) and anterior cerebral artery aneurysms (1, 4, 13, 18, 21, 32). However, the frontal sinus (FS) is often opened during this surgery, and various postoperative complications may occur as a result of the open FS, including cerebrospinal fluid (CSF) leakage and infection (e.g., meningitis, brain abscess, subdural abscess, epidural abscess, and subcutaneous or subperiosteal abscess) (5, 8, 10, 17, 18, 20, 22, 25, 26, 32). The mucosa of the FS tends to form mucocele, especially if the nasofrontal duct (NFD) is obstructed. Such FS mucoceles have a slow and insidious tendency to enlarge, resulting in late-onset infection in some cases (29). Various methods have been employed for reconstruction of the anterior skull base, including cranialization and obliteration of the FS (3, 11, 16, 23, 24, 30). Cranialization involves elimination of the posterior wall of the FS, meticulous removal or coagulation of the FS mucosa, and allowing the frontal lobe to rest against the anterior table and floor of the FS (11). Obliteration involves permanent occlusion of the frontal recess and physical obliteration of the FS (11). Numerous methods for obliteration of the FS have been reported, including the use of fat, fascia, muscle, galeal or pericranial flap, bone, and titanium plates (2-4, 6, 8, 11, 16, 23-25, 30). However, CSF leakage and infection are major postoperative problems, with reported frequencies of 2%e20% and 3%e20%, respectively (5, 8, 10, 17, 18, 20, 22, 25, 26, 32). More effective methods for FS reconstruction are needed to decrease the complication rate. For many years, we have used a surgical technique based on direct suture of the exposed and violated FS mucosa because it is important to leave the NFD open and to seal the FS mucosa completely. However, this technique has rarely been reported and discussed (19). In the present study, we describe in detail
From the 1Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama; 2Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido; and 3 Department of Neurosurgery, Abashiri Neurosurgical and Rehabilitation Hospital, Abashiri, Hokkaido, Japan To whom correspondence should be addressed: Satoru Takeuchi, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015) 83, 6:907-911. http://dx.doi.org/10.1016/j.wneu.2015.01.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
907
FORUM SATORU TAKEUCHI ET AL.
FRONTAL SINUS RECONSTRUCTION AFTER BIFRONTAL CRANIOTOMY
our procedure for treating the exposed FS during bifrontal craniotomy and discuss the results and outcomes of our procedure.
MATERIALS AND METHODS This study was conducted with the approval of the ethics committee of the National Defense Medical College. The committee concluded that written informed consent was not required because of the retrospective nature of the investigation. This study included 103 patients (68 women and 35 men; age range, 32e90 years; mean age, 62.6 years) who underwent bifrontal craniotomy with FS exposure and mucosal violation for frontal base lesions, including anterior cerebral artery aneurysm (22 ruptured and 78 unruptured cases), arteriovenous fistula (1 case), and meningioma (2 cases), between November 2010 and May 2014 at 2 hospitals (Teishinkai Hospital and Abashiri Neurosurgical and Rehabilitation Hospital). In all 103 patients, FS reconstruction was performed using direct suture of the exposed and violated FS mucosa as described subsequently. Retrospective chart review was used to collect demographic data, including age, sex, indication for surgery, presence of postoperative complication (CSF leakage, infection, and mucocele formation), and follow-up findings. Surgical Technique of Bifrontal Craniotomy The patient was placed in the supine position. The head was placed slightly above the level of the heart. A bicoronal skin incision that covered the forehead was made behind the hairline (Figure 1A). The skin flap was separated from the periosteum with the subgaleal connective tissue. After incision and elevation of the periosteum, 2 or 3 burr holes were made in the frontal region depending on the size of the FS, and craniotomy was performed in a temple bell shape (Figure 1B). The medial-inferior craniotomy margin was the root of the nose. The FS was exposed in most cases (21).
Surgical Technique of FS Reconstruction After opening the FS (Figure 2A), the posterior wall of the FS was eliminated, and the mucosal membrane of the FS was dissected from the FS wall. Hemostasis against refractory bleeding from the FS wall was performed using monopolar coagulation. The NFD was kept open by washing thoroughly to prevent retention of any bone dust and clot in the FS using an irrigation and suction system (Ohwa Tsusho Co., Ltd., Tokyo, Japan) developed by Kamiyama et al. (14) (Figure 2B). The margin of the orifice of the FS mucosa was stained with pyoktanin blue to improve visualization and was closed with 7-0 monofilament running sutures (Figure 2C and D). Absorbable gelatin sponge (Gelfoam; Pfeizer Inc., NY, USA) soaked in fibrin glue was attached to the sutured area (Figure 2E). The cavity of the FS was packed with abdominal fat mixed with fibrin glue (Figure 2F). After complete dural closure, the bone flap was returned to the skull. The periosteum, subcutaneous tissue, and skin were closed in layers (21). Postoperative Management Antibiotics (cefazolin 2 g/day) were administered for 2 days. The patients were required to avoid sneezing for 3 months. CSF leakage was defined as persistent postoperative leakage of a glucose-containing serous liquid from the nasal cavities. Patients with postoperative meningeal signs or high fever were required to undergo CSF examination and magnetic resonance imaging or computed tomography or both to detect the presence of meningitis, brain abscess, subdural abscess, epidural abscess, or subcutaneous or subperiosteal abscess. Magnetic resonance imaging or computed tomography was routinely performed 3 months after surgery and annually thereafter to detect such complications. RESULTS The follow-up period was 3e45 months (mean, 16 months). Postoperative CSF leakage and mucocele formation did not occur in any patient. An intracranial infectious complication occurred in
Figure 1. Intraoperative photographs of the interhemispheric approach. The patient was placed in the supine position. The head was placed slightly above the level of the heart. A bicoronal skin incision covering the forehead was made behind the hairline (A). The craniotomy was performed in a temple bell shape after incision and elevation of the periosteum (B).
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Figure 2. Intraoperative photographs of frontal sinus (FS) reconstruction. After opening the FS (A), the posterior wall of the FS was eliminated, and the mucosal membrane of the FS was dissected from the FS wall. The nasofrontal duct was kept open by washing thoroughly using an irrigation and suction system (B). The margin of the orifice of the FS mucosa was
1 patient, a 59-year-old man with a past history of diabetes mellitus. He underwent clipping for an unruptured distal anterior cerebral artery aneurysm via bifrontal craniotomy. The FS was exposed and reconstructed as described previously. After surgery, he was asked to avoid sneezing, but he sneezed frequently. He experienced a fever 2 months after surgery, and an epidural abscess was diagnosed. He underwent removal of the bone flap. He underwent cranioplasty 6 months later. He was healthy with no neurologic deficit 21 months after the first surgery. DISCUSSION CSF leakage as a complication of open FS after bifrontal craniotomy rarely resolves spontaneously and can cause infectious complications or pneumocephalus, and additional surgery or spinal CSF drainage is often required (6, 9, 27, 28). In addition, infectious complications can result from the formation of mucocele (29). These complications can lead to postoperative worsening and extended hospitalization. Several materials for obliteration of the FS are available (2-4, 6, 8, 11, 16, 23-25, 30); we used abdominal fat with fibrin glue (3, 23, 30) because we believe that use of artificial materials should be avoided, and the volume of fat is easy to adjust to the size of the FS defect. However, obliteration with fat only can prevent a dead space but cannot prevent the formation of mucocele and subsequent infection (30). The frequencies of mucocele development and infection after obliteration with fat only are approximately 10% and 3%, respectively. We believe that fat obliteration should be combined with methods to prevent mucocele formation.
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stained with pyoktanin blue to improve visualization and was closed with 7-0 monofilament running sutures (C and D). Gelfoam sponge soaked in fibrin glue was attached to the sutured area (E). The cavity of the FS was packed with abdominal fat mixed with fibrin glue (F).
Generally, the FS mucosa is stripped away or coagulated regardless of the method of obliteration (7, 8, 30). This procedure may prevent some CSF leakage, but mucocele may be formed by obstruction of the NFD, resulting in late-onset infection. Our methods for maintaining the patency of the NFD and direct suture of the exposed and violated FS mucosa are more reliable to prevent the formation of mucocele and seal the FS mucosa completely compared with removal or coagulation of the FS. The present study to our knowledge is the largest series to date to report direct suture of the exposed and violated FS mucosa for FS reconstruction. Previously, 51 consecutive patients underwent bifrontal craniotomy with exposed and violated FS (19). The surgical technique included direct suture of the exposed and violated FS mucosa with pericranial flap, and none of the 51 patients developed postoperative CSF leakage or meningitis (19). In the present study, the frequencies of CSF leakage and infectious complications were 0% and 1.0%, respectively, which are significantly lower than frequencies previously reported. We think that past history of diabetes mellitus and frequent sneezing might have contributed to the development of a postoperative infectious complication in the 1 affected patient. It is well known that approximately 3 months is required for complete epithelialization of the wounded paranasal sinuses (12, 31), so we recommended that sneezing should be avoided during this period. The previous and the present findings indicate that direct suture of the exposed and violated FS mucosa results in reduced risks of postoperative CSF leakage and infectious complications. We think that maintaining the patency of the NFD is the most important factor to prevent the formation of mucocele, which causes lateonset infection. The irrigation and suction system, which we have
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routinely used to maintain the clean operative field for many years (14), was quite useful to remove bone dust and clot in the NFD, resulting in maintaining the patency of the NFD. In addition to the above-mentioned advantage, we consider that direct suture of the mucosa has some further merits. First, direct suture under the operating microscope is a very useful practice for young neurosurgeons to improve their microsurgical suturing skills (15). Laboratory training may be essential to gain microneurosurgical experience, but the relaxed and static environment is not comparable to that of the operating room, where the stress of actual surgery imposes entirely different demands on the surgeon (15). Our policy is consistent with such an approach to training. Second, this method does not require spinal CSF drainage, so drainage-related complications, including low intracranial pressure, intracranial hematoma, and infection, can be avoided (19).
REFERENCES 1. Chhabra R, Gupta SK, Mohindra S, Mukherjee K, Bapuraj R, Khandelwal N, Khosla VK: Distal anterior cerebral artery aneurysms: bifrontal basal anterior interhemispheric approach. Surg Neurol 64:315-319, 2005. 2. Costa H, Cerejo A, Baptista A, Vaz R, Gonçalves M, Guimarães A: The galea frontalis myofascial flap in anterior fossa CSF leaks. Br J Plast Surg 46:503-507, 1993. 3. Donald PJ, Ettin M: The safety of frontal sinus fat obliteration when sinus walls are missing. Laryngoscope 96:190-193, 1986. 4. El-Noamany H, Nakagawa F, Hongo K, Kakizawa Y, Kobayashi S: Low anterior interhemispheric approach—a narrow corridor to aneurysms of the anterior communicating artery. Acta Neurochir 143:885-891, 2001. 5. Feiz-Erfan I, Han PP, Spetzler RF, Horn EM, Klopfenstein JD, Kim LJ, Porter RW, Beals SP, Lettieri SC, Joganic EF: Preserving olfactory function in anterior craniofacial surgery through cribriform plate osteotomy applied in selected patients. Neurosurgery 57 (1 Suppl):86-93, 2005. 6. Fliss DM, Gil Z, Spektor S, Leider-Trejo L, Abergel A, Khafif A, Amir A, Gur E, Cohen JT: Skull base reconstruction after anterior subcranial tumor resection. Neurosurg Focus 12:e10, 2002.
The present study has some limitations. We evaluated the state of the NFD only by intraoperative microscopic observation, and we could not assess accurately the patency of the NFD. Further studies using fiberoptic transillumination may be required to investigate whether our methods can maintain complete patency of the NFD. In addition, we failed to investigate the usefulness of our methods statistically because of the lack of an appropriate comparison group. Further studies are also necessary on this point. CONCLUSIONS Maintenance of the patency of the NFD and direct suture of the exposed and violated FS mucosa with fat obliteration is a reliable and effective method to prevent postoperative complications after opening of the FS.
vascularized outer table calvarial bone graft. Neurosurgery 36:725-731, 1995. 11. Horowitz G, Amit M, Ben-Ari O, Gil Z, Abergel A, Margalit N, Cavel O, Wasserzug O, Fliss DM: Cranialization of the frontal sinus for secondary mucocele prevention following open surgery for benign frontal lesions. PLoS One 8:e83820, 2013. 12. Hosemann W, Wigand ME, Göde U, Länger F, Dunker I: Normal wound healing of the paranasal sinuses: clinical and experimental investigations. Eur Arch Otorhinolaryngol 248:390-394, 1991. 13. Ito S, Fujimoto S, Saito K, Tada H, Tanaka T: Postoperative olfactory dysfunction in interhemispheric approach for ruptured anterior communicating artery aneurysms [in Japanese]. No Shinkei Geka 24:625-628, 1996. 14. Kamiyama H, Abe H, Nomura M, Saito H, Yasui N: Acute stage operations for cerebral aneurysms, intracerebral hematomas, arterio-venous malformation high pressure irrigation and suction system [in Japanese]. Surg Cereb Stroke 16: 282-286, 1988. 15. Kivelev J, Hernesniemi J: Four-fold benefit of wound closure under high magnification. Surg Neurol Int 4:115, 2013. 16. Kryzanski JT, Annino DJ Jr, Heilman CB: Complication avoidance in the treatment of malignant tumors of the skull base. Neurosurg Focus 12:e11, 2002.
Tamakawa N, Moroi J, Suzuki A, Yasui N: CSF leakage and anosmia in aneurysm clipping of anterior communicating artery by basal interhemispheric approach [in Japanese]. No Shinkei Geka 39:263-268, 2011. 21. Noda K, Tanikawa R, Kamiyama H, Ohta N, Yabuuchi T, Miyata S, Kosaka A, Tsuboi T, Tokuda S: Interhemispheric approach for Acom aneurysm [in Japanese]. Jpn J Neurosurg 21: 834-841, 2012. 22. Schramm VL Jr, Maroon JC: Sinus complications of frontal craniotomy. Laryngoscope 89:1436-1445, 1979. 23. Sessions RB, Alford BR, Stratton C, Ainsworth JZ, Shill O: Current concepts of frontal sinus surgery: an appraisal of the osteoplastic flap-fat obliteration operation. Laryngoscope 82:918-930, 1972. 24. Sinha UK, Johnson TE, Crockett D, Vadapalli S, Gruen P: Three-layer reconstruction for large defects of the anterior skull base. Laryngoscope 112:424-427, 2002. 25. Siniscalchi EN, Angileri FF, Mastellone P, Catalfamo L, Giusa M, Conti A, De Ponte FS, Tomasello F: Anterior skull base reconstruction with a galeal-pericranial flap. J Craniofac Surg 18: 622-625, 2007. 26. Tosun F, Gonul E, Yetiser S, Gerek M: Analysis of different surgical approaches for the treatment of cerebrospinal fluid rhinorrhea. Minim Invasive Neurosurg 48:355-360, 2005.
7. Fujiwara H, Yasui N, Nathal-Vera E, Suzuki A: Anosmia after anterior communicating artery aneurysm surgery: comparison between the anterior interhemispheric and basal interhemispheric approaches. Neurosurgery 38:325-328, 1996.
17. Kryzanski JT, Annino DJ, Gopal H, Heilman CB: Low complication rates of cranial and craniofacial approaches to midline anterior skull base lesions. Skull Base 18:229-241, 2008.
8. Goel A: Multilayer reconstruction of the anterior cranial fossa floor. Br J Neurosurg 12:254-258, 1998.
18. Meetze K, Palmer JN, Schlosser RJ: Frontal sinus complications after frontal craniotomy. Laryngoscope 114:945-948, 2004.
27. Tuettenberg J, Czabanka M, Horn P, Woitzik J, Barth M, Thomé C, Vajkoczy P, Schmiedek P, Muench E: Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure. J Neurosurg 110:1200-1208, 2009.
9. Guppy KH, Silverthorn JW, Akins PT: Subarachnoid hemorrhage due to retained lumbar drain. J Neurosurg Spine 15:641-644, 2011.
19. Murai Y, Mizunari T, Kobayashi S, Teramoto A: Surgical technique for the prevention of cerebrospinal fluid leakage after bifrontal craniotomy. World Neurosurg 81:344-347, 2014.
28. Van Velthoven V, Clarici G, Auer LM: Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery. Acta Neurochir 109:26-29, 1991.
20. Nakayama H, Ishikawa T, Yamashita S, Fukui I, Mutoh T, Hikichi K, Yoshioka S, Kawai H,
29. Wallis A, Donald PJ: Frontal sinus fractures: a review of 72 cases. Laryngoscope 98:593-598, 1988.
10. Hasegawa M, Torii S, Fukuta K, Saito K: Reconstruction of the anterior cranial base with the galeal frontalis myofascial flap and the
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30. Weber R, Draf W, Keerl R, Kahle G, Schinzel S, Thomann S, Lawson W: Osteoplastic frontal sinus surgery with fat obliteration: technique and longterm results using magnetic resonance imaging in 82 operations. Laryngoscope 110:1037-1044, 2000. 31. Xu G, Jiang H, Li H, Shi J, Chen H: Stages of nasal mucosal transitional course after functional
endoscopic sinus surgery and their clinical indications. ORL J Otorhinolaryngol Relat Spec 70: 118-123, 2008. 32. Yasui N, Nathal E, Fujiwara H, Suzuki A: The basal interhemispheric approach for acute anterior communicating aneurysms. Acta Neurochir 118:91-97, 1992.
Citation: World Neurosurg. (2015) 83, 6:907-911. http://dx.doi.org/10.1016/j.wneu.2015.01.030 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
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