Reconstruction of the Large Frontal Sinus Defect With the Small Supporting Bone Pieces in Neurosurgical Anterior Skull Base Surgery.

BACKGROUND: Large defects of frontal sinus (FS) might be difficult to manage effectively. Mismanagement of the large defects could lead to serious postoperative complications in anterior skull base surgery. This study introduces a simple and reliable method applying small supporting bone pieces to cover or insert into large FS defects, then the large defect of FS was transformed into the small defects which was sealed by bone wax successfully. METHODS: Eleven patients underwent anterior skull base surgery for lesions or aneurysms, with the reconstruction of large FS defects by small supporting bone pieces. During craniotomy, mild violations of the FS mucosa were spared and sterilized, while severe violations required mucosal removal. Small supporting bone pieces were obtained from the inner plate of the bone flap and carefully covered or inserted into the large defects. The large defects were transformed into some small ones, which could be sealed effectively by bone wax. Demographic, intraoperative, and postoperative complication data were collected. RESULTS: Four patients had severe mucosal violations requiring removal, while 7 had mild violations sparing the mucosa. All underwent effective reconstruction with small supporting bone pieces. Median follow-up was 6 months. All cases showed effective FS morphology reconstruction, with no FS-related complications. CONCLUSIONS: Applying the small supporting bone pieces for large FS defect reconstruction can restore the FS morphology, preserve physiological function, and avoid postoperative complications.

Application of binasal speculum in endoscopic endonasal surgery for lesions in sellar region.

Objective: This study aims to access the efficacy of the binasal speculum in endoscopic endonasal surgery by evaluating clinical outcomes and examining its utility through process-based performance measures in both surgeons and assistants. Methods: A total of 59 patients with lesions in sellar region who underwent endoscopic endonasal surgery with the binasal speculum between September 2020 and March 2023 were included in this study. We assessed the extent of resection and documented postoperative nasal condition. Both surgeons and assistants completed post-use surveys to exam the utility of the binasal speculum and provide an overall grading. Results: Gross total resection (GTR) was successfully achieved in 94.9% (56/59) of patients, with subtotal resection (STR) observed in 5.1% (4/59) of patients. Intraoperative cerebrospinal fluid (CSF) leakage occurred in 23.7% (14/59) of cases, and nasoseptal flap (NSF) reconstruction was required in 55.9% (33/59) of cases. The nasal airway patency rapidly recovered within 14 days in a significant majority of patients (94.9%, 56/59). Moreover, olfactory function was regained within three months postoperatively by 91.5% (54/59) of patients. The overall post-use survey mean score was 26.4. Specifically, surgeons had a mean score of 26.5, while assistants had a slightly lower mean score of 26.2. The mean overall grading for the binasal speculum was 3. Both surgeons and assistants provided a mean overall grading of 3. Conclusion: The binasal speculum provides nasal mucosa protection and reduces the risk of an endoscopic lens clouded by mucosa or blood. It plays a crucial role in accurate guidance and facilitates the swift delivery of surgical instruments, particularly in left-blinded nasal cavities. The binasal speculum reduces the learning curve, especially for endoscopic surgeons with limited experience, while enhancing collaboration and coordination between surgeons and assistants during surgery. Both surgeons and assistants rated the overall utility of the binasal speculum as "excellent."

Intraoperative Injection of Normal Saline Through Lumbar Drainage for Transnasal Endoscopic Repair of Complex CSF Leaks.

Objective: It is well known that accurate location of the leak in the operation is crucial for repairing cerebrospinal fluid leakage. The study aims to investigate the application of intraoperative injection of normal saline through lumbar drainage in repairing complex leaks. Methods: The fistulas of all patients with CSF leak were located by computed tomography cisternography (CTC) or heavy T2 magnetic resonance imaging (MRI) before surgery. Before anesthesia, the patient underwent lumbar drainage implantation, and then 20 ml of normal saline was slowly injected through the lumbar drainage to observe the patient's response. The surgical approach was designed based on the preoperative imaging data. When the operation was near to the suspected fistula, normal saline was injected through lumbar drainage (20 ml each time) to confirm the leak location. After CSF leak repair, saline was injected again to confirm whether the repair was successfully. Result: Of the 5 patients with complex leaks, 4 cases were repaired by transnasal endoscopy method, and 1 case was repaired by transnasal endoscopy method and epidural method. A total of 7 leaks were found during the operation. During the operation, 40-120 ml of normal saline was injected through lumbar drainage. Cauda equina neuralgia was developed in patients who received 120 ml normal saline, which was relieved by intrathecal injection of dexamethasone. During the follow-up of 3 months, 1 case suffered from brain abscess, which was controlled by vancomycin. There was no recurrence of rhinorrhea. Conclusion: Intraoperative injection of normal saline through lumbar drainage can not only better expose the complex leak but also check the repair effect of the leak during transnasal endoscopic repair, which is effective and avoids side effects.

Combined intra- and extra-endoscopic techniques for endoscopic intraventricular surgery with a new mini-tubular port.

Objective: Intraoperative hemorrhage represents a major risk during endoscopic intraventricular surgery. There are very few publications describing the maintenance of hemostasis during conventional endoscopic intraventricular surgery. Here, we designed a new mini-tubular port to combine intra- and extra-endoscopic techniques for endoscopic intraventricular surgery. With this new methodology, complicated techniques can be performed more efficiently with improved bleeding control. Methods: The new mini-tubular port consists of an outer sheath and an obturator. The sheath is a thin-walled transparent cylinder that is 0.35 mm thick, 10 mm in diameter, and 90 mm in length. In this report, we describe the use of the mini-tubular port on 36 patients receiving endoscopic intraventricular surgery. Results: The study enrolled 36 patients, with a median age of 45 years (range: 0-72 years), of which 19 were male and 17 were female. Pure ETV (endoscopic third ventriculostomy) was performed in 20 patients and pure biopsy was performed in 2. ETV and biopsy were performed in five patients, ETV and the removal of cysticerci were performed in five, cyst fenestration was performed in one, ETV and cyst fenestration were performed in two, and ETV and shunt removal were performed in one patient. Two patients received microscopic surgery following endoscopic surgery during the same operation. A total of 17 patients (47%) underwent extra-endoscopic techniques. The median Karnofsky Performance Status (KPS) score of the patients prior to surgery was 50, while the median KPS score of the patients after one month of surgery was 80; these scores were significantly different (P < 0.05), as determined by Wilcoxon's test. In total, 27 patients had a KPS score ≥70% and 75% of patients had a favorable prognosis one month after surgery. None of the patients experienced seizure. Conclusion: The new mini-tubular port can conveniently combine intra- and extra-endoscopic techniques for endoscopic intraventricular surgery. The application of these techniques can efficiently control bleeding during surgery, help improve the confidence of the surgeons involved, and provide a highly efficient approach for performing complicated procedures.