Komplikationen bei Operationen an der Rhinobasis

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

[Autologous fibrin glue for endoscopic skull base repair in patients with cerebrospinal fluid leakage]

The main stages of endoscopic skull base repair in patients with cerebrospinal fluid (CSF) leakage are identification of bone boundaries of the fistula and its closure by auto- and allografts. Fibrin glue can be used to fix plastic materials and additionally seal skull base defect.

OBJECTIVE

To analyze efficacy and safety of Vivostat autologous fibrin glue for endoscopic skull base repair in patients with nasal CSF leakage and to compare postoperative outcomes after defect closure by Vivostat fibrin glue and allogeneic fibrin glue.

MATERIAL AND METHODS

A retro- and prospective analysis included 56 patients with nasal CSF leakage who were treated at the Burdenko Neurosurgery Center between January 2021 and June 2022. Patients were divided into 2 groups: Vivostat fibrin glue (n=27, 48.2%) and allogeneic fibrin glue (n=29, 51.8%). Demographic and clinical perioperative data were analyzed.

RESULTS

No early postoperative recurrence of CSF leakage was registered in both groups, whereas meningitis occurred in 2 cases in each group. Recurrent CSF leakage in delayed postoperative period occurred in 1 patient (3.4%) of the control group (p>0.05). Incidence of perioperative complications, subfebrile temperature in early postoperative period, surgery time and hospital-stay were similar.

CONCLUSION

Vivostat autologous fibrin glue is a safe and effective method for fixing the grafts in endoscopic skull base repair. The advantages of this approach are easy application, elimination of the risk of allergic, immunological and infectious complications, as well as acceleration of tissue regeneration.

The use of three-dimensional endoscope in transnasal skull base surgery: A single-center experience from China

Objective

The development of skull base surgery in the past decade has been influenced by advances in visualization techniques; recently, due to such improvements, 3D endoscopes have been widely used. Herein, we address its effect for transnasal endoscopic skull base surgery.

Methods

A total of 63 patients who under endoscopic endonasal surgery (EES) with 3-D endoscope were retrospectively reviewed, including pituitary adenomas, craniopharyngiomas, meningiomas, Rathke’s cleft cysts, and chordomas. According to different lesions, transsellar approach (24 cases), transsphenoidal–transtuberculum approach (14 cases), transclival approach (6 cases), and transpterygoid approach (19 cases) were selected.

Results

Total removal of tumors was achieved in 56 patients (88.9%) and subtotal removal in 7 cases (11.1%). Complications included diabetes insipidus in seven patients (11.1%), cerebrospinal fluid (CSF) leakage in two patients (3.2%), major vascular injury occurred in one patient (1.6%), cranial nerve injury in nine patients (14.3%), and meningitis in two patients (3.2%). There was no mortality in the series. All patients recovered and were back to normal daily life, and no tumor recurrence or delayed CSF leakage was detected during the follow-up (2–13 months, mean 7.59 months).

Conclusions

Via 3D EES, it improved depth perception and preserved important neurovascular tissue when tumors were removed, which is important for improving the operative prognosis.

Effects of CT/MRI Image Fusion on Cerebrovascular Protection, Postoperative Complications, and Limb Functional Recovery in Patients with Anterior and Middle Skull Base Tumors: Based on a Retrospective Cohort Study

Objective. To explore the effect of CT/MRI image fusion on cerebrovascular protection, postoperative complications and limb function recovery in patients with anterior and middle skull base tumors. Methods. During January 2019 to December 2021, a retrospective study was conducted on 50 patients who underwent anterior and middle skull base tumor resection in the same surgeon group in our hospital. According to the different surgical approaches, the patients were assigned to the fusion group (n = 29) and the routine group (n = 21). The routine group was operated with traditional operation, and the fusion group was operated with CT/MRI image fusion technique. The operation time, wound volume, resection rate and Karnofsky performance status (KPS), blood transfusion (vascular protection), tumor resection rate, and postoperative complications were compared. Results. The time of operation in the fusion group was shorter compared to the routine group, and the volume of the wound cavity in the fusion group was smaller compared to the routine group, and the difference was statistically significant ( $P<0.05$ ). Following treatment, the KPS score of the fusion group was remarkably higher compared to the routine group, and the difference was statistically significant ( $P<0.05$ ). The intraoperative blood transfusion rate in the fusion group was 17.24%, and the intraoperative blood transfusion rate in the routine group was 47.62%, and the difference was statistically significant ( $P<0.05$ ). The resection rate in the fusion group (89.66%) was remarkably higher compared to the routine group (61.90%, $P<0.05$ ). The incidence of postoperative complications in the fusion group (6.90%) was remarkably lower compared to the control group (33.33%, $P<0.05$ ). Conclusion. The application of CT/MRI image-fusion technology can effectively enhance the clinical symptoms of patients with tumors in the anterior and middle region of the skull base, which can promote the prognosis, shorten the operation time, reduce unnecessary cerebral neurovascular injuries, and retain more brain functions.

Biological Treatments of Neurofibromatosis Type 2 and Other Skull Base Disorders

Studies of genomic alterations that occur in skull base tumors have provided information regarding biological aberrations that are necessary for the growth and maintenance of these tumors. This has led to the development and initiation of clinical trials incorporating biological treatments for many skull base tumors. The exciting developments of molecularly targeted therapy for the treatment of skull base tumors may provide noninvasive therapeutic options for patients that can be used either alone or in combination with surgery and/or radiation therapy. Future analysis and continued scientific discovery of treatments for skull base tumors can lead to improved outcomes in patients.

Revision Surgery Technique in the Treatment of Refractory Subcutaneous Cerebrospinal Fluid Collection Combined with Intracranial Infection Following Posterior Fossa Surgery

Objective

Cerebrospinal fluid (CSF) leakage remains the most common and serious complication following posterior fossa surgery. Persistent subcutaneous CSF collections can cause wound dehiscence and predispose patients to intracranial infection. Management with conservative treatment fails in up to 40% of patients, and revision surgery remains the last resort. We hereby introduce a novel surgical technique using muscle graft or pedicled trapezius muscle flaps to repair dura and skull base defect for the treatment of subcutaneous CSF collections refractory to conservative management.

Methods

A retrospective chart review was conducted for six patients who presented to our institution from 2012 to 2020, with subcutaneous CSF collections following posterior fossa surgeries and had undergone revision surgeries after unsuccessful management with conservative treatments. Patient demographics, etiologies, culture results, revision procedures, follow-ups, and recurrences of fluid collections were collected.

Results

Of these six patients, two underwent repair of dura and skull base defect with pedicled trapezius muscle flaps, and four had arachnoid fistula repaired with autologous muscle graft. All six patients fully recovered. CSF leakage and subcutaneous fluid collections were resolved. No recurrences occurred upon the last follow-ups.

Conclusion

A revision surgery using muscle graft or pedicled trapezius muscle flaps to repair the dura and skull base defect is effective at treating persistent cerebrospinal fluid leakage and subcutaneous fluid collection refractory to conservative treatment.

[Possible surgical approaches to the orbit]

For removal of tumors and foreign bodies from the orbit, for treatment of severe inflammatory diseases, and for repositioning of bone fragments following fractures or during reconstruction of the bony orbit, several different surgical approaches are available. During the past decade, improved understanding of the pathology and pathophysiology of particular orbital diseases, advancements in clinical endoscopy and microscopy, the introduction of modern imaging techniques for preoperative visualization of pathologic findings, modern approaches to orbital reconstruction, as well as developments in adjuvant therapy have led to a reduction in invasiveness and development of the modern minimally invasive surgical approaches to the orbit usually used today. This review article aims to describe several surgical approaches to the orbit that are nowadays commonly applied-frequently in the context of interdisciplinary therapy-as well as their indications and potential complications. Particular attention is paid to minimally invasive approaches. These different surgical approaches allow a 360-degree exposure of the internal orbital structures with the optic nerve at the center ("round the clock access to the orbit"). The review is complemented by hints and tricks for particular approaches, as well as by a review of the latest literature in the field.