Differentiated approach to plastic surgery of cerebrospinal fluid fistulas in the frontal sinus based on the analysis of computed tomograms

Abstract

The choice of the method of plasty of cerebrospinal fluid fistulas in the area of the frontal sinus is an important issue in neurosurgery, since there are a large number of anatomical variations in the structure of the naso-frontal canal and the sinus itself. Endoscopic, combined and transcranial approaches are described in the literature. However, there is no clear algorithm for choosing a surgical approach for nasal liquorrhea based on anatomical features. The objective of this article is to study various anatomical variants of the structure of the frontal sinus and nasolabial pocket in relation to defects of the base of the skull of a given localization and, based on the data obtained, to establish the patterns of the influence of certain indicators on surgical tactics and the quality of plastic to complement the proposed classification. This article include a retrospective analysis of case histories and computed tomograms of 38 patients who underwent surgical treatment for skull base defects in the frontal sinus region from 2010 to 2020. The patients were divided into three groups depending on the approach used, the features of intraoperative visualization of the defect, and relapses. In a series of 38 cases, the endoscopic approach was used in 26 (68.4 %) cases, combined in 12 (31.6 %) cases. The defect was completely visualized using angled optics during surgery in 32 (84.2 %) cases, and in 6 (15.8 %) cases the defect was not visualized or partially visualized (up to 50 %) using angled optics. Relapses were observed in 6 (15.8 %) cases. The main craniometric indicators affecting the choice of surgical tactics and the quality of plastics are the distance from the center of the defect to the nasal septum, the value of the angle between the nasal septum and the line drawn through the edges of the defect, and the size of the defect. The recurrence rate is directly related to the visualization of the defect during surgery. The distance from the defect to the nasal septum can serve as an objective indicator for choosing access to intermediate defects of the frontal sinus: at a distance of more than 0.95 cm, it is advisable to perform a combined approach; at a distance of less than 0.95 cm, it is possible to achieve full visualization of the defect and perform high-quality plastic surgery with an endoscopic approach. English version of the article on pp. 244-253 is available at URL: https://panor.ru/articles/differentiated-approach-in-frontal-sinus-csf-fistula-plasty-based-on-computed-tomogram-analysis/63924.html