Management of dural lesions occurring during endonasal sinus surgery

Abstract

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.