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Successful endoscopic endonasal repair of nasal meningoencephalocele in a 21-day-old neonate.

Mohindra S, Mohindra S, Patro SK - Allergy Rhinol (Providence) (2015)

Bottom Line: We present the youngest patient of nasal meningoencephalocele successfully repaired via endoscopic approach.Radiological investigation showed a cribriform plate defect on the right side.This is feasible even in the neonatal period due to improved technique and instrumentation now available for endoscopic nasal surgeries.

View Article: PubMed Central - PubMed

Affiliation: Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

ABSTRACT

Introduction: Indications of surgical intervention in congenital nasal meningoencephaloceles includes presence of cerebro spinal fluid rhinorrhea having a risk of causing meningitis, episodes of prior meningitis and bilateral nasal obstruction causing respiratory difficulty in these obligate nasal breathers. Many authors would like to wait till the patient attains the age of 2 to 3 years for repair of the defect due to surgical feasibility. However, early intervention prevents further episodes of meningitis in the future. We present the youngest patient of nasal meningoencephalocele successfully repaired via endoscopic approach.

Case report: A 21 days old neonate was referred to us with a nasal meningoencephalocele with active cerebrospinal fluid rhinorrhoea. Radiological investigation showed a cribriform plate defect on the right side. Repair was done by endoscopic route by multi-layered closure of the defect which was augmented with a mucoperichondrial flap from the septum. Patient was asymptomatic in the post-operative follow up period and did not have any episode of meningitis till date.

Conclusion: Early repair by transnasal endoscopic route is a feasible surgical option for congenital anterior skull base defects with meningoencephaloceles to prevent further episodes of meningitis. This is feasible even in the neonatal period due to improved technique and instrumentation now available for endoscopic nasal surgeries.

No MeSH data available.


Related in: MedlinePlus

(A) Clinical photograph immediately after diagnostic endoscopy; note the stretching of the nostril due to the endoscope. (B) T2-weighted MRI, coronal section, showing an intense soft tissue density in the right nasal cavity, which is communicating with intracranial contents; the white arrow points to a possible flow void. (C) T2-weighted MRI, sagittal section, showing an intense soft tissue density occupying the whole right nasal cavity; the white arrow points to a defect in the cribriform plate. (D) Endoscopic view of the meningoencephalocele sac; note the irregular surface due to an earlier attempted removal. (E) Endoscopic view of the septomucosal flap that was used to plug the defect after excision of the meningoencephalocele. (F) Repeat endoscopy at 5 months postoperative period, showing a completely healed right nasal cavity. MRI, magnetic resonance imaging.
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Figure 1: (A) Clinical photograph immediately after diagnostic endoscopy; note the stretching of the nostril due to the endoscope. (B) T2-weighted MRI, coronal section, showing an intense soft tissue density in the right nasal cavity, which is communicating with intracranial contents; the white arrow points to a possible flow void. (C) T2-weighted MRI, sagittal section, showing an intense soft tissue density occupying the whole right nasal cavity; the white arrow points to a defect in the cribriform plate. (D) Endoscopic view of the meningoencephalocele sac; note the irregular surface due to an earlier attempted removal. (E) Endoscopic view of the septomucosal flap that was used to plug the defect after excision of the meningoencephalocele. (F) Repeat endoscopy at 5 months postoperative period, showing a completely healed right nasal cavity. MRI, magnetic resonance imaging.

Mentions: An 11-day-old infant was referred to us after attempted endonasal removal of a polyp at a different facility. When we examined her, the infant was having right-sided active watery nasal discharge, which was not foul smelling and which increased during crying. There was no history of fever, seizures, excessive cry, or feeding difficulties. Birth history was uneventful. There was an associated history of respiratory difficulty since birth, which was aggravated during sleep. Results of biochemical and cytologic analysis of the discharge were suggestive of CSF. Glucose and protein levels and total and differential leukocyte counts were within normal ranges for CSF. The fluid was positive for the presence of β transferrin. Magnetic resonance imaging revealed a meningoencephalocele protruding from a defect in the right cribriform plate (Fig. 1B, C). Nasal endoscopy revealed a pale pinkish mass with an irregular surface that completely occupied the right nasal cavity and displaced the septum to the opposite side. (Fig. 1D). By using zero degree 2.7-mm nasal endoscope, the meningoencephalocele sac was electrocauterized at the cribriform plate by using bipolar diathermy and was debrided at the site of the defect by using a pair of scissors. Mucosa at the margins of the defect was debrided by using a microdebrider to delineate the bony margin of the defect. At each attempt during the surgery the instrument was introduced first, followed by the endoscope to visualize the surgical field because the dimensions of the anterior nares were too small to accommodate both if introduced together (Fig. 1A). A view could even be obtained by keeping the endoscope at the nares. The defect was sealed by a rotated posterior-based nasal septomucosal flap (single-layered repair) (Fig. 1E). The repair of the defect was further augmented with the application of fibrin glue, and hemostasis was achieved to end the procedure. Lumbar drainage was not done during the postoperative period because of the age of the neonate to avoid any procedure-related complication and infections. The patient was given antibiotic prophylaxis with antimeningitic doses of ceftriaxone during the postoperative period for 7 days. She was discharged on postoperative day 7. The patient is under our continuous follow-up to date. An nasal endoscopy was performed at the 5-month follow-up, which showed a well-healed skull base without any CSF leak or skull base defect or encephalocele (Fig. I F). A magnetic resonance cisternography picture taken during the follow-up showed the absence of any encephalocele or active CSF leak. (Fig. 2).


Successful endoscopic endonasal repair of nasal meningoencephalocele in a 21-day-old neonate.

Mohindra S, Mohindra S, Patro SK - Allergy Rhinol (Providence) (2015)

(A) Clinical photograph immediately after diagnostic endoscopy; note the stretching of the nostril due to the endoscope. (B) T2-weighted MRI, coronal section, showing an intense soft tissue density in the right nasal cavity, which is communicating with intracranial contents; the white arrow points to a possible flow void. (C) T2-weighted MRI, sagittal section, showing an intense soft tissue density occupying the whole right nasal cavity; the white arrow points to a defect in the cribriform plate. (D) Endoscopic view of the meningoencephalocele sac; note the irregular surface due to an earlier attempted removal. (E) Endoscopic view of the septomucosal flap that was used to plug the defect after excision of the meningoencephalocele. (F) Repeat endoscopy at 5 months postoperative period, showing a completely healed right nasal cavity. MRI, magnetic resonance imaging.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4541634&req=5

Figure 1: (A) Clinical photograph immediately after diagnostic endoscopy; note the stretching of the nostril due to the endoscope. (B) T2-weighted MRI, coronal section, showing an intense soft tissue density in the right nasal cavity, which is communicating with intracranial contents; the white arrow points to a possible flow void. (C) T2-weighted MRI, sagittal section, showing an intense soft tissue density occupying the whole right nasal cavity; the white arrow points to a defect in the cribriform plate. (D) Endoscopic view of the meningoencephalocele sac; note the irregular surface due to an earlier attempted removal. (E) Endoscopic view of the septomucosal flap that was used to plug the defect after excision of the meningoencephalocele. (F) Repeat endoscopy at 5 months postoperative period, showing a completely healed right nasal cavity. MRI, magnetic resonance imaging.
Mentions: An 11-day-old infant was referred to us after attempted endonasal removal of a polyp at a different facility. When we examined her, the infant was having right-sided active watery nasal discharge, which was not foul smelling and which increased during crying. There was no history of fever, seizures, excessive cry, or feeding difficulties. Birth history was uneventful. There was an associated history of respiratory difficulty since birth, which was aggravated during sleep. Results of biochemical and cytologic analysis of the discharge were suggestive of CSF. Glucose and protein levels and total and differential leukocyte counts were within normal ranges for CSF. The fluid was positive for the presence of β transferrin. Magnetic resonance imaging revealed a meningoencephalocele protruding from a defect in the right cribriform plate (Fig. 1B, C). Nasal endoscopy revealed a pale pinkish mass with an irregular surface that completely occupied the right nasal cavity and displaced the septum to the opposite side. (Fig. 1D). By using zero degree 2.7-mm nasal endoscope, the meningoencephalocele sac was electrocauterized at the cribriform plate by using bipolar diathermy and was debrided at the site of the defect by using a pair of scissors. Mucosa at the margins of the defect was debrided by using a microdebrider to delineate the bony margin of the defect. At each attempt during the surgery the instrument was introduced first, followed by the endoscope to visualize the surgical field because the dimensions of the anterior nares were too small to accommodate both if introduced together (Fig. 1A). A view could even be obtained by keeping the endoscope at the nares. The defect was sealed by a rotated posterior-based nasal septomucosal flap (single-layered repair) (Fig. 1E). The repair of the defect was further augmented with the application of fibrin glue, and hemostasis was achieved to end the procedure. Lumbar drainage was not done during the postoperative period because of the age of the neonate to avoid any procedure-related complication and infections. The patient was given antibiotic prophylaxis with antimeningitic doses of ceftriaxone during the postoperative period for 7 days. She was discharged on postoperative day 7. The patient is under our continuous follow-up to date. An nasal endoscopy was performed at the 5-month follow-up, which showed a well-healed skull base without any CSF leak or skull base defect or encephalocele (Fig. I F). A magnetic resonance cisternography picture taken during the follow-up showed the absence of any encephalocele or active CSF leak. (Fig. 2).

Bottom Line: We present the youngest patient of nasal meningoencephalocele successfully repaired via endoscopic approach.Radiological investigation showed a cribriform plate defect on the right side.This is feasible even in the neonatal period due to improved technique and instrumentation now available for endoscopic nasal surgeries.

View Article: PubMed Central - PubMed

Affiliation: Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

ABSTRACT

Introduction: Indications of surgical intervention in congenital nasal meningoencephaloceles includes presence of cerebro spinal fluid rhinorrhea having a risk of causing meningitis, episodes of prior meningitis and bilateral nasal obstruction causing respiratory difficulty in these obligate nasal breathers. Many authors would like to wait till the patient attains the age of 2 to 3 years for repair of the defect due to surgical feasibility. However, early intervention prevents further episodes of meningitis in the future. We present the youngest patient of nasal meningoencephalocele successfully repaired via endoscopic approach.

Case report: A 21 days old neonate was referred to us with a nasal meningoencephalocele with active cerebrospinal fluid rhinorrhoea. Radiological investigation showed a cribriform plate defect on the right side. Repair was done by endoscopic route by multi-layered closure of the defect which was augmented with a mucoperichondrial flap from the septum. Patient was asymptomatic in the post-operative follow up period and did not have any episode of meningitis till date.

Conclusion: Early repair by transnasal endoscopic route is a feasible surgical option for congenital anterior skull base defects with meningoencephaloceles to prevent further episodes of meningitis. This is feasible even in the neonatal period due to improved technique and instrumentation now available for endoscopic nasal surgeries.

No MeSH data available.


Related in: MedlinePlus