POSTOPERATIVE DIAGNOSIS(ES):
Ruptured posterior wall of the frontal sinus.
OPERATIONS PERFORMED:
Craniotomy for exenteration of a frontal sinus along with harvesting and
use of a vascularized pericranial graft.
COMPLICATIONS:
None.
DISPOSITION:
The patient was transferred in stable condition to the ICU.
SUMMARY:
The patient was brought to the operating room and underwent uneventful
intubation. Preoperative dose of mannitol, steroids, and antibiotics was
given. The patient time-out was performed. The patient was placed with
the Mayfield pins up. A curvilinear ??<__________> superior incision was
planned based on the patient's preoperative wishes which he did not wish
for a Z incision. The patient was then prepped in the usual fashion
including alcohol, followed by chlorhexidine, followed by DuraPrep, all of
them x2. The patient was draped in the usual sterile fashion. Local
anesthetic was used to anesthetize the skin. A 15-blade was used to score
the epidermis. I then used snaps to be able to split the skin and galea
from the pericranium. Using that technique, I was able to open the
incision without injuring the pericranium. A pericranial ??<__________>
graft was elevated, first using the monopolar to Bovie the periphery and
then elevating with a periosteal elevator. A pericranial flap had been
injured in the area of his previous injury and was repaired using 3-0
Vicryl. Of note is that subperiosteal dissection was then carried down all
the way to the orbital rims. The skin was then flapped down and held in
place with hooks and of note is that underneath the skin I had placed
Kerlixes that were bunched up into cigars in order to avoid any acute
angles at the skin of the forehead and avoid any closure of that skin. The
periphery was then covered with Ray-Tecs which were kept moist during the
entire case. Following that, 2 bur holes were created on the right and on
the left and the AM-8 was used to drill a burr off the central part of the
calvaria to avoid any injury to the sinus. A periosteal elevator was used
to elevate the dura. A router was then used to go ahead and elevate the
bone flap. This did come across the sinus anterior and posterior wall as
expected. Following that, the bone flap, I went ahead and removed the
posterior wall of the sinus from the bone flap and went ahead and used the
high-speed drill to drill away the entire surface of the remaining anterior
surface of the frontal sinus that was on the bone flap in order to remove
all mucus-producing cells. This was done with a high-speed drill. Of note
is that the correction of the anterior deficit was performed by Plastic
Surgery. Following that, I went ahead and placed tack-up sutures around
the periphery of the craniotomy, waxed the bony bleeding and went ahead and
placed both FloSeal and Surgicel around the gutters and tacked it up with
tack-up sutures. Following that, I went ahead and exenterated the sinus by
removing the posterior wall of the sinus using the Leksell and the
high-speed drill. This actually had surprisingly large nasal frontal ducts
and as seen by the preoperative CAT scan had pneumatized orbital rims for
walls. For that reason, extensive removal of the posterior wall was
performed, leaving a very small ledge all the way in the back in order to
be able to anchor the material with which I would pack the nasal frontal
sinus. After I was satisfied with the resection of the posterior wall, I
went ahead and then used the diamond drill to again drill off all cells
producing any mucus in order to avoid a mucocele formation in the future.
This was done using a high-speed drill and no irrigation so that I could
constantly see where I had previously drilled. Very careful attention was
made to not skip or miss any point with the drilling with the high-speed
diamond drill. I was very satisfied with the cleaning of the sinus.
Of note is that prior to that, I had stripped any of the obvious sinus
mucosa using a periosteal freer and had packed it down marsupializing it
into the nasal frontal duct. Of note is that there was no evidence of any
leakage of CSF from any areas of the dura. Following that, I went ahead
and packed the nasal frontal duct with Gelfoam that had been soaked in
antibiotic bacitracin ointment. I went ahead and then imbricated the
pericranial graft inwards, packing it down into the nasal frontal duct. I
used a parachute technique in order to secure it down deep into the dura.
4-0 Nurolon was used for that reason. This was done in order to imbricate
the pericranial graft down into the nasal frontal duct and to the area
where the previous sinus existed. This was done again using a parachute
technique. At that point, I inspected for any bleeding, and any bleeding
was controlled using bipolar cautery. The remainder of the operation,
including the replacement of the craniotomy and the closure, was performed
by Plastic Surgery. Of note is that I did place 2 tack-up stitches on the
dura centrally which Plastic Surgery would tent up through the craniotomy
once they replaced it. The patient tolerated my part of the procedure with
no complications.
