Management of dural lesions occurring during endonasal sinus surgery
R. Weber, R. Keerl, W. Draf, B. Schick, P. Mosler and A. Saha
Department of Ear, Nose, and Throat Diseases, Head, Neck, and Facial Plastic Surgery, Communication Disorders, Hospital Fulda, Germany.
BACKGROUND: Dural lesions incurred during endonasal sinus surgery must be
repaired surgically because of the risk of potentially fatal late
meningitis. DESIGN: Retrospective survey. SETTING: Ear, nose, and throat
department of a university teaching hospital. PATIENTS: Consecutive sample
of 47 patients who had undergone duraplasty for repair of a dural lesion
that occurred as a complication of endonasal sinus surgery. Forty-two
patients were interviewed after an average postoperative period of more
than 5 years. INTERVENTION: Endonasal duraplasty, external duraplasty
(fronto-orbital or transfrontal extradural approach) by underlay or onlay
technique. MAIN OUTCOME MEASURES: Fluorescein test (intrathecal
administration of fluorescein sodium and subsequent nasal endoscopy),
subjective complaints, history of meningitis, cerebrospinal fluid
rhinorrhea, or hyposmia. RESULTS: There were 44 endonasal and 3 external
duraplasties (2 by the fronto-orbital and 1 by the transfrontal extradural
approach); the underlay technique was used in 25 and the onlay technique in
22. The fluorescein test, performed in 43% (20/47) of the patients was
negative in all cases. Twenty-six percent of the patients had had 1 or more
episodes of bacterial sinusitis without meningitis. Duraplasty was
clinically intact in 100%. Postoperative olfactory disturbances were
reported in 17%. CONCLUSIONS: Duraplasty can be performed satisfactorily by
the endonasal route, thus avoiding the disadvantages of the fronto-orbital
approach (visible scar, risk of damage to the supraorbital nerve, and
removal of bone from the floor of the frontal sinus with a tendency to
stenosis of the nasofrontal duct and subsequent mucocele). Allogeneic
connective tissue in combination with fibrin glue has proved suitable as a
graft material.
