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Table of Contents
ORIGINAL ARTICLE
Year : 1998  |  Volume : 1  |  Issue : 1  |  Page : 17-26

Endonasal dura repair: Techniques and results


1 Department of Otolaryngology, Head and Neck Surgery, Facial Plastic Surgery, Communication Disorders, Hospital Fulda, Academic Teaching Hospital of the University of Marburg, Germany
2 Department of Otolaryngology, Head and Neck Surgery, Facial Plastic Surgery,Communication Disorders.Hospital Fulda, Academic Teaching Hospital of the University of Marburg, Germany

Date of Web Publication16-Jun-2020

Correspondence Address:
MD Bernhard Schick
Department of tolaryngology, Head and Neck Surgery, Facial Plastic Surgery, Communication Disorders Hospital Fulda Academic Teaching Hospital of the University of Marburg Pacelliallee 4 D-36043 Fulda
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.286852

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  Abstract 


Frontobasal dura repair is necessary to prevent endocranial inflammations. However, identification and treatment of frontobasal dural lesions is still a challenge inregard to aetiology, location and size. The endonasal approach for duraplasty was recommended recently to provide a safe and effective repair of anterior skull base defects.
The authors review their experiences with endonasal duraplasty. Diagnostic aspects and surgical techniques of proven value in endonasal repair of dural lesions are presented. From July 1980 to July 1996, 95 duraplasties have been performed in 92 patients via an endonasal approach at the ENT-Department, Fulda. A successful duraplasty was accomplished in 89 patients (97%) in the first attempt. In 2 patients, endonasal duraplasty had to be repeated to achieve a safe closure. In one case ofcomplex fractures of the sphenoid sinus and lateral skull base after a severe accident, the duraplasty of the sphenoid sinus was unsuccessful and an endonasal revision was indicated, but the patient died of cardiovascular shock. The Follow up period was from I to 16 years.
Endonasal micro-endoscopic surgery offers the opportunity to repair frontobasal dural lesions in a safe and effective manner. Due to its low morbidity, high success rate and good long-term result, endonasal duraplasty is recommended as a main treatment modality in frontobasal dural lesions.

Keywords: CSF - dural lesion - diagnostic - surgery - endonasal approach - duraplasty


How to cite this article:
Schick B, Tahan AE, Brors D, Mosler P, Draf W. Endonasal dura repair: Techniques and results. Saudi J Otorhinolaryngol Head Neck Surg 1998;1:17-26

How to cite this URL:
Schick B, Tahan AE, Brors D, Mosler P, Draf W. Endonasal dura repair: Techniques and results. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 1998 [cited 2022 Nov 30];1:17-26. Available from: https://www.sjohns.org/text.asp?1998/1/1/17/286852




  Introduction Top


Dural lesions in the neighborhood of paranasal sinuses are dangerous to the patients because potentially fatal meningitis or cerebral abscesses may occur until safe dural closure is gained. Even in cases of spontaneous closure of the dura without surgical repair, the resulting dural scar is often too thin to provide an adequate barrier against sinus infections. In traumatology, late meningitis, has been observed in 3-50% of frontobasal dural injuries that have not been repaired.[1],[2],[3]

Dural lesions can occur spontaneously or as a result of trauma, surgery or tumours. Dural injuries were observed in up to 2,5% of the cases as a complication of endonasal surgery for inflammatory paranasal sinus diseases.[4]

The treatment of frontobasal CSF-fistulas has been a challenge. Dandy (1926)[5] described a successful intracranial repair of a dural lesion behind the posterior wall of the frontal sinus suturing a fascia lata graft over the tear. De Almeida (1928)[6] reported cauterisation of two dural lesions with either50% chromic acid or with a platinum loop with cure in the former case while the latter patient died of encephalitis. Sgalitzer (1930)[7] mentioned treatment of 13 patients with CSF-leakage by X-ray with the aim to inhibit the production of CSF and reported success by this treatment modality in 1930. Dohlmann (1948)[8] mentioned an extracranial approach to repair a frontobasal CSF-fistulas surgically. Hirsch (1952)[9] used endonasal surgery to close dural lesions of the sphenoid sinus. Vrabec and Hallberg (1964) [10] reported endonasal repair of dural leaks in the region of the cribriform plate.

Despite these first experiences, external approaches were mainly recommended in the past based on the opinion that an endonasal approach did not provide a sufficientview to the anterior skull base. [8],[11] Technical improvements (endoscope, microscope) and increasing experiences in endonasal surgery lead to more frequent use of endonasal duraplasty as reported by different authors [Table 1][12],[13],[14],[15],[16],[17],[18] who proved the ability of successful endonasal management of dural lesions. Therefore, endonasal duraplasty is nowadays recommended as the treatment modality of choice for a large number of frontobasal dural lesions. In this article, we review endonasal treatment of dural lesions in regard to preoperative investigations, techniques and results.
Table 1: Results of endonasal duraplasty in major series

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Surgical techniques

Endonasal surgery means an approach through the natural orifice of the nose supported by optical aids (endoscope, microscope). Self- retaining speculums and the microscope permit a bimanual operation under binocular vision. Modified ear instruments (elongated round knife, incision flap knife, sickle knife, elevators) have provedto be suitable in endonasal duraplasty.

Depending on the location and size of the dural lesion different techniques are available. The underlay technique [Figure 1] can be used to close defects of the posterior wall of the frontal sinus in its inferior part, of the ethmoid roof and sometimes in the sphenoid sinus. The graft is inserted between dura and bone. Whenever possible we cover the graft by a mucosal flap from its neighbouring site in order to accelerate epithelialization. The duraplasty can be further covered by absorbable materials before nasal packing with the aim to prevent a tearing opening of the duraplasty by removing nasal packing. The same principle of covering with mucosa and absorbable material holds true for the onlay technique, which may be chosen especially for defects of the cribriform plate and the sphenoid sinus. In the onlay technique [Figure 1] the graft is placed directly over the dura lesion and its surrounding bone. There is no risk of damage to nerves or vessels by raising the intact dura from the surrounding bone. Furthermore, the underlay and onlay techniques can be combined to close a CSF-fistula.
Figure 1: Illustration showing the onlay technique to close a dura lesion at the posterior wall of the frontal sinus (demonstration of the onlay technique for illustrative reasons, but mainly the underlay technique is chosen in this location ),this underlay technique to repair a dura leak of the ethmoid roof and fat obliteration of the sphenoid cavity after inserting a piece of abdominal fat directly into the bony defect. (1=dura,2=bone,3=graft,4=mucosal flap,5=absorbable materials, 6=nasal packing).

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Surgical treatment of CSF-leakage in the sphenoid sinus can demand special techniques. Due to the close neighborhood of the internal carotid artery, cavernous sinus and cranial nerves (II, III, IV, VI), surgical manipulations have to be restricted. In addition, because of the large basal cisterns the surgeon is confronted with aprofuse escape of CSF. Besides the underlay and onlay procedures, the tobacco pouch technique according to Kley 12 [Figure 2] or an abdominal fat obliteration of thesphenoid sinus [Figure 1] may be necessary. Furthermore, a small piece of tissue like abdominal fat or fascia lata can be wedged into the bony defect to reduce the CSFpressure on the duraplasty.
Figure 2: Tobacco pouch formed by fascia lata and filled with gelatine sponge and cellulose.

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Different graft materials are mentioned in the literature. From a general point of view autologous materials (fascia lata, abdominal fat, bone of the middle turbinate, mucosa of the nasal cavity, perichondrium, cartilage) and allogenic grafts have to be distinguished. Synthetic materials have also been used for duraplasty.


  Materials and Methods Top


This retrospective study covers all records of patients who had undergone endonasal repair of a frontobasal dural lesion at the ENT- department Fulda in a 16 year period. From 1/07/1980 to 1/07/1996, 95 duraplasties were performed in 92 patients by an endonasal approach. Evaluation included the following aspects: aetiology, location, surgical technique, and results of endonasal dura repair. The hospital course, postoperative control examinations and the results of phone calls were available. The follow up period ranged from I to 16 years.

High-resolution CT scan was performed with I mm slice thickness. For CT-cisternography 20 ml Iotrolan-300 (Isovist®, Schering, Berlin, Germany) was used as the contrast medium introduced through a lumbar puncture under X- ray control. For nasal fluorescein endoscopy, no more than 1 ml sterile, freshly prepared 5% sodiumfluorescein solution (0,1 ml 5% fluorescein solution/10 kg body weight) should be introduced by lumbar puncture. Prior to nasal fluorescein endoscopy or CT- cisternography, a hearing test was performed as hearing loss is one of the possible side effects of fluorescein or contrast medium application.

For duraplasty underlay or onlay technique, mainly allogenic connective tissue (Tutoplast® Biodynamics International, Erlangen, Germany) was used. Abdominal fat and fascia lata were taken as autologous grafts. Native bovine collagen (Tissue Vlies ®, Immuno AG, Heidelberg, Germany) or cellulose (Tabotamp ®, Johnson & Johnson Medical, UK) were available as absorbable materials. Dura grafts nasal mucosa flaps and the covering absorbable materials were additionally fixed with fibrin glue (Tisse, ®, Immuno AG, Heidelberg, Germany). Nasal packing was removed 3 to 14 days after surgery, and in most cases antibiotic prophylaxis was assured with cefuroxime given as long as the nasal packing was in place. Postoperatively, in no patient management with lumbar CSF drainage was used.

All patients were recommended to undergo a clinical and endoscopic control examination including nasal fluorescein endoscopy 2 to 3 months after surgery. In addition, for this retrospective evaluation the patients were asked by phone calls about the following symptoms: transient or recurrent watery nasal secretion, episodes of meningitis and acute bacterial sinusitis.

A duraplasty was judged to be tight if the patients gave no history of watery nasal discharge, recurrent meningitis or meningitis in spite of acute bacterial sinusitis, and when control examinations were uneventfull. Four patients were already deceased by the time of the phone calls without reported signs of endocranial complications. Two patients could not be reached, though we would expect to be contacted by these patients in case of complications.


  Results Top


Between July 1980 and July 1996, 95 duraplasties have been performed in 92 patients via an endonasal approach. Fifty dura lesions had been caused by paranasal sinus surgery in our department or somewhere else, one dura lesion was detected after septoplasty, 21 dura injuries were caused by trauma, in 18 cases dura was resected in tumor surgery with the need for closure, and in 2 cases dura lesion was presented as a malformation. The dura lesions were located at the posterior wall of the frontal sinus in 8,4% (N=8), the cribriform plate in 31,6% (N=30), the ethmoid roof in 35,8% (N=34) and the sphenoid sinus in 20% (N=19) of the cases. In 4 cases (4,2%) the dura lesion affected the ethmoid roof and the lamina cribrosa.

The underlay technique was chosen in 27,4% (N=26) and the onlay procedure performed in 48,4% (N=46). Underlay and onlay techniques were combined to repair 16 (16,8%) of the dural lesions. In 5 cases the tobacco pouch technique was required to close a CSF-leakage in the sphenoid sinus, and obliteration of the sinus with abdominal fat was accomplished in another 2 cases. In addition to the onlay technique or the tobacco pouch technique, a piece of abdominal fat was inserted into the fracture line of the sphenoid sinus in order to reduce the CSF pressure before duraplasty. In 6 patients the endonasal duraplasty was combined with external approaches to close ,transnasaly not accessible, dura lesions. In case of multiple skull base fractures, only the dura lesions in the sphenoid sinus have been treated endonasaly. Allogenic tissue was used as graft in 84 patients, autologous tissue ( fascia lata or abdominal fat) was used in 5 patients and a combination of allogenic and autologous tissue chosen in 3 patients.

In 89 patients the dura fistula was closed in the first attempt. Endonasal revision of the duraplasty was necessary in three cases:

  1. A traumatic dura injury of the sphenoid sinus had been closed by abdominal fat obliteration, but CSF-rhinorrhoea persisted. During revision surgery, fat obliteration was repeated after inserting a piece of abdominal fat directly into the fracture gap in order to reduce the CSF pressure.
  2. A CSF-fistula at the ethmoid roof caused by paranasal sinus surgery for treatment of a chronic inflammatory disease was finally closed by revision of duraplasty.
  3. In one case of complex fractures of the sphenoid sinus and lateral skull base due to a severe accident with multiple injuries we were faced with a profuse CSF-rhinorrhoea. The duraplasty of the sphenoid sinus was unsuccessful and an endonasal revision was indicated, but the patient died before that due to cardiovascular shock.


The recommendation of clinical and endoscopic control examination including nasal fluorescein endoscopy was followed by 52 patients (56,5%). No fluorescein was detected in the paranasal sinuses or nasal cavity as cause of an insufficient frontobasal duraplasty. The remaining 40 patients refused nasal fluorescein endoscopy. By phone call we were able to interview 49 of 92 patients. Four patients had died of other causes in the intervening period without evidence of insufficient duraplasty.

Based on this retrospective study we were able to achieve a closure of the dura lesion in 97% after one surgical intervention, and a tight duraplasty in all remaining cases (91/92) available for surgery including 2 endonasal revisions.


  Discussion Top


Frontobasal dural lesions need a safe closure. Until appropriate duraplasty is achieved the patient will remain at risk of potentially fatal meningitis or cerebral abscesses. Occult dural lesions can become symptomatic due to meningitis or CSF-rhinorrhoea even decades after trauma.[2] The physician should, therefore, be aware to notice symptoms of dural lesions as meningitis caused by upper airway pathogens, recurrent meningitis or CSF- rhinorrhoea. Up to 80% of the dural leaks are caused by traumas, and 16% are related to surgical dura injuries.[20] Only 3-4% occur spontaneously as high or low pressure leaks according to Ommaya et al (1968). [21] A CSF- leakage can be proved by determining the albumin/prealbumin-ratio or 132-transferrin determination in watery nasal discharge.[22],[23] But thin dura scars can stop CSF-rhinorrhoea or mild rhinorrhoea which escapes the patients notice if the fluid drains via the nasopharynx. Furthermore genuine CSF-rhinorrhoea must be distinguished from intermittent pseudo-CSF- rhinorrhoea caused by watery secretion of sinus cysts. The laboratory analysis of the secretions will be negative in these cases and the intermittent nasal discharge ceases after removal of the cyst.[24]

To localise a dural lesion we gained experience with 4 techniques in close cooperation with our radiology department: high- resolution CT, magnetic resonance imaging, nasal fluorescein endoscopy and CT- cisternography.

  1. High-resolution CT is a basic diagnostic tool to search for a dural lesion. Trauma is the most expected cause for a dura injury and can be visualised indirectly due to a fracture line or intradural air bubbles [Figure 3]a, [Figure 3]b, [Figure 3]c. To visualise bony defects of the ethmoid roof, cribriform plate or roof of the sphenoid sinus, imaging in coronal view is the best. Imaging in the axial plane offers advantages in detecting bony defects of the posterior wall of the frontal sinus and the lateral/posterior borders of the sphenoid sinus. CT examination is now available almost everywhere as a diagnostic procedure prior to duraplasty in order to localise the dural lesion and to choose the best possible approach. Sensitivity for detection of a dural lesion, particularly in traumatic cases is mentioned in 84 to 100% .2,20 Small, mainly non-traumatic dural lesions can escape detection in high- resolution CT.
  2. Detection of CSF-fistulas can be reached by magnetic resonance imaging (MRI) without any radiation risk. Success rate of MRI in imaging CSF-fistulas is reported to be 66 to 100% .[25] In case of good contrast due to unaffected paranasal sinuses a CSF-fistula can be visualised as T2-weighted MRI examinations demonstrate CSF as a bright signal. On the other hand thickened mucosa, cysts or polyps in the paranasal sinuses can hinder the attempt to prove a CSF-fistula by MRI due to their signal intensity in T2-weighted imaging. Up to 25%, inflammatory changes were found accidentally in paranasal sinuses by MRI in patients with no paranasal symptoms which were examined for other reasons. [26]
  3. Nasal fluorescein endoscopy can be used in order to detect and localise a dural lesion, to support duraplasty and to prove the success of surgical dura repair. [27],[28] With white and blue filters the nasal cavity, paranasal sinuses and nasopharynx are examined endoscopically to search for a frontobasal CSF-leakage. Detection of yellowish-green fluorescent fluid points to a CSF-Ieak. In some cases the yellow- green colour can be seen shimmering through the delicate mucous membrane covering a dural lesion. During surgery, fluorescein application, facilitates the localisation of the dural lesion exactly and to verify intra-operatively a tight closure of the leak [Figure 4]a, [Figure 4]b.
    Figure 3: A 41 year old male patient was reffered, after entonasal pansinus operation to our department with suspicion of intra-operative dura lesion.The axial CT examination showed a bony defect at the anterior ethmoid roof (a), intradural air bubbles (b) and a signifigant pneumatocephalus behind the frontal sinus (c)

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    Figure 4: CSF fistula of the ethmoid roof indicated by fluorescein (a) and closur of the dural lesion after inserting an allogenic graft by underlay technique (b)

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    Use of nasal fluorescein endoscopy is controversial. Authors who recommend this technique pinpoint to the benefits of fluorescein -marked CSF and their good experiences without serious complications.[28],[4] On the other hand seizure, infections, disordered sensation of the lower extremities, opisthotonos and cranial nerve deficits are mentioned as severe complications after fluorescein application .[28] Based on our own experience we agree with others that nasal fluorescein endoscopy is a valuable support for the localisation of frontobasal dural lesions and endonasal duraplasty. The use of sterile, freshly prepared fluorescein solution and the lumbar puncture application of only the necessary amount of 5% fluorescein solution (0,Iml 5% fluorescein solution/10 kg body weight, never more than I ml) should be adhered to in order to prevent complications.
  4. Intrathecal administration of Iotrolan as contrast medium by lumbar puncture is another technique to visualise a CSF-leakage directly during CT examination [Figure 5]. The correct time for CT examination is indicated by opacification of the cisterns. Fluorescein nasal endoscopy and CT-cisternography should never be combined at the same time to prevent seizures.
Figure 5: CT Cisternography demonstrating a fracture of the sphenoid roof with opacification of the left sphenoid cavity by CSF

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CT-Cisternography was mentioned to be the most precise diagnostic tool in localisation of a dural lesion . [29],[30] However, a CSF leakage can notbe detected in all cases with this technique. Colquhoun (1993)[31] reported a success rate of 81% in 21 CT-cisternographies. We were able to localizeprecisely a dural lesion by CT-cisternography in five out of eight cases (62.5%). In general, the ability to prove a CSF- leakage by the use of contrast mediums depends whether there is an active or inactive CSF- fistula at the time of examination. A success rate of 92% in active CSF-rhinorrhoea and 40% in inactive CSF-leaks was enumerated by Eljamel el et al. (1994).[32]

In recent years different authors [Table 1][12],[13],[14],[15],[16],[17],[18] emphasised the ability for safe frontobasal dura repair by an endonasal approach. The advantages of endonasal duraplasty are decreased morbidity, high success rate and good long-term results. All authors report good results by an endonasal approach while a wide variety of different materials (free mucosal grafts from the middle and inferior turbinates, combined mucosa- perichondrium-(bone)-graft, fascia lata, abdominal fat, muscle or allogenic tissues) were used as grafts. The inserted graft acts as a scaffold for the wound healing process of the dura .[4] By enzymatic and cellular processes the graft will be replaced by endogeneous connective tissue. Pedicled mucosal flaps from the surrounding area are used to cover the graft in order to accelerate epithelialisation and wound healing.

Endonasal repair of dural lesions at the cribriform plate has to take into account the maintenance of olfactory function. In case of intact sense of smell and high risk of damage to the olfactory fibres due to endonasal repair, we discuss with our neurosurgical colleagues whether an intradural approach offers a better chance to preserve the olfactory function. Small pieces of abdominal fat can be fixed between the olfactory fibres under direct vision after a small fronto-temporal craniotomy. Furthermore, the transnasal approach can be used in combination with extranasal procedures. A transfrontal extradural approach is chosen in extended frontal skull base fractures to cover large defects with a galea-periosteum flap if the patient lost already his sense of smell. Otherwise the intradural approach with preservation of the olfactory tract and fibres is the technique of choice under these circumstances. By these intracranial techniques a CSF-leak in the sphenoid sinus can be difficult to close. If it persists afterwards, the additional endonasal approach is successful in most cases.

As endonasal surgery has proven to close dural lesions with satisfactory results the fronto- orbital approach is not used any longer by us except when a soft tissue damage in this region has already occurred. The disadvantages of the fronto-orbital approach (visible scar, risk of damage of the supraorbital nerve, tendency to stenosis of the nasofrontal drainage with subsequent mucocele formation due to bone removal) can be avoided by an endonasal procedures. If a dural lesion of the posterior wall of the frontal sinus can not be reached endonasally, which depends on location of the dura injury and the anterior-posterior diameter of the infundibulum, weprefer an osteoplastic procedure.


  Conclusion Top


Precise localisation of a frontobasal dural lesion is the necessary prerequisite for successful surgical repair guarding the patient of against the risk of potentially fatal meningitis or cerebral abscesses. High-resolution CT, MRI, nasal fluorescein endoscopy and CT cisternography are recommended diagnostic tools to assure the diagnosis. Depending on aetiology, location and size of the dura injury the proper surgical approach is chosen. The endonasal approach offers safe closure of a largenumber of dura leaks and is therefore recommended as the approach of first choice. In case of dura injury of the cribriform plate and intact sense of smell, extended frontobasal fractures and endonasally not reachable dura lesions of the posterior wall of the frontal sinus, an extra- or intradural intracranial approach has to be taken into consideration.



 
  References Top

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