Amalu Thomas, (2022) Analysis of the Success Rates of Pedicled Grafts Vs Free Grafts for Endoscopic CSF Rhinorrhea Repair. Masters thesis, Madras Medical College, Chennai.
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Abstract
INTRODUCTION Cerebrospinal fluid (CSF) rhinorrhea occurs from breakdown of physiological barriers that separate subarachnoid space from nasal cavity. It results in direct communication between subarachnoid space and nasal cavity. It paves the way for spread of bacterial pathogens leading to significant morbidity (ascending meningitis). It may result from traumatic, iatrogenic, neoplastic, congenital, inflammatory causes. The diagnosis and localization may be problematic, but newer strategies has helped in making diagnosis easier. The main principle of skull base reconstruction is to create a watertight seal, thus separating cranium and sinonasal cavity thus reconstructing the barrier for infections. Elimination of dead space, preservation of ocular and neurological functions and promote wound healing are main aims of leak repair. Surgical management is indicated when medical management fails. CSF rhinorrhea was traditionally treated with open surgical approaches, invention of endoscopes have brought a revolutionary change in its management. Walter Dandy first described successful intracranial repair through bifrontal craniotomy in 1926. Wigand later described transnasal endoscopic repair using fibrin glue to seal skull base defect. AIMS AND OBJECTIVE: 1. Study of different types of grafts and pedicled flaps used in CSF rhinorrhea repair. 2. Analysis of the efficacy and success rates of pedicled and free grafts. 3. Efficacy based on site and size of leak. MATERIALS AND METHODS: STUDY PLACE: Rajiv Gandhi Government General Hospital, Chennai- 600003. COLLABORATING DEPARTMENT: Upgraded Institute Of Otorhinolaryngology. STUDY DESIGN: Prospective study. STUDY PERIOD: February 2020- July 2021. SAMPLE SIZE: 30. BENEFIT TO THE COMMUNITY: ❖ Regular post surgical follow up for the patients. ❖ Detection of the use of which graft yields better results. CONFLICT OF INTEREST: Nil FINANCIAL SUPPORT: Nil INCLUSION CRITERIA: a. Both the genders above the age of 12 yrs. and below 70 yrs. b. Defects detected endoscopically or radiologically. c. Failure of conservative management. d. Etiology- Traumatic, iatrogenic and spontaneous CSF leaks. e. Skull base defects less than 3cm. EXCLUSION CRITERIA: 1. Age below 12yrs and above 70 yrs. 2. Defects not detected endoscopically or radiologically. 3. Leaks requiring intracranial approach. 4. Sinonasal and intracranial malignancy. 5. Generalised systemic illness (not fit for anaesthesia). 6. Laterally placed leaks where endoscopy is not feasible. 7. History of surgery to turbinates or sphenopalatine artery ligation. METHOD: After obtaining ethical committee approval. 30 patients satisfying inclusion criteria were selected. History, examination findings noted. Routine blood investigations, CSF analysis, nasal endoscopy, CT paranasal sinuses, CT cisternogram and MRI (optional) were done to diagnose CSF leak. Out of 30 patients, CSF repair was done with free grafts for 15 cases and with pedicled grafts for another 15. Post surgical follow up of patients were done in the immediate postoperative period, first, second week, first and third month. Intraoperative complications was assessed by the presence of excessive bleeding, orbital complications, pneumocephalus etc. Postoperative assessment was done by history taking, diagnostic nasal endoscopy, and checking for the development of complications like headache, infection, meningitis, duration of postoperative stay, recurrence, crust formation on endoscopy. Data was collected and entered in Microsoft Excel. Later for categorical variables frequency distribution were calculated and for association Chi square test were used. Statistical analysis was done using SPSS software version 18.Results were finally concluded. CONCLUSION: CSF rhinorrhea repair is important to prevent the development of meningitis and resulting morbidity and mortality. In this study we wanted to study of the success rates of different grafts used in CSF repair. Graphs were made and the data were analysed. ❖ In this study incidence of CSF rhinorrhea was found to be more among females, mostly around the age of 40 yrs ❖ Most of the cases were of spontaneous etiology, second commonest cause was due to trauma. ❖ Placement of grafts depends on the site of the defect hence it was important to find the level of cribriform plate and thus the importance of Keros classification. In this study iatrogenic trauma were commonly associated with Keros type 2 and 3. ❖ Fascia lata, middle turbinate, sliced septal cartilage, tragal cartilage autograft, and inferior turbinate bone were used in this study. Among them fascia lata was commonly used. But no much difference was found among them in relation to the outcome. ❖ Hadad-Bassegasteguy flap based on nasoseptal artery and middle turbinate flap based on posterior lateral nasal artery, were the pedicled flaps used in our study. Hadad flap was most commonly used. But no significant difference was found in between them regarding outcome. ❖ Pedicled flaps were more preferred for larger sized defects. ❖ Both midline and lateral defects, had equal outcome with pedicled and free grafts. ❖ Type of graft used was found to be independent of the site of defect, incidence of postoperative complications and recurrence. ❖ In mucormycosis, since there is devitalisation of tissues, pedicled grafts had better uptake than free grafts due to its intrinsic blood supply. ❖ Crust formation which is an indicator of poor healing was found more common among free grafts. Thus regarding postoperative healing pedicled grafts are better. ❖ Thus the successful repair of CSF rhinorrhea repair relies on multiple factors. Besides the skill of the surgeon and sterility of the procedure, associated comorbidities, site, size of the defect, approaches used and the tissues used for repair are the deciding factors.
| Item Type: | Thesis (Masters) |
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| Additional Information: | 221914005 |
| Uncontrolled Keywords: | Analysis, Success Rates, Pedicled Grafts, Free Grafts, Endoscopic CSF Rhinorrhea Repair. |
| Subjects: | MEDICAL > Otolaryngology > MEDICAL > Otolaryngology |
| Depositing User: | Subramani R |
| Date Deposited: | 18 Apr 2022 10:27 |
| Last Modified: | 17 Dec 2023 03:35 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/19350 |
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