Endonasal breach
The bony area separating the brain and meninges from the nasal cavity, sinuses and eyes is known as the anterior stage of the skull base. The anterior stage of the skull consists of the frontal, ethmoid and sphenoid bones. The brain is surrounded by 3 meninges (pia mater, arachnoid, dura mater) and bathed in cerebrospinal fluid. Occasionally, a bone breach can cause cerebrospinal fluid to pass from the brain to the sinuses and nose, or even from the middle ear to the nose via the eustachian tube. The passage of meningeal fluid (meningocele) or even brain fluid (encephalocele) through the breach is much rar
Find out more about endonasal breach closure from Dr. Delagranda, ENT and cervico-facial surgeon in la Roche sur Yon.
Skull base, anterior stage and endonasal osteomeningeal gap
The internal bony base of the skull is divided into three stepped pits (anterior, middle and posterior). The anterior cranial fossa or anterior third part is the highest, with the other 2 following in a stair-step pattern. ENT practitioners “commune” practice only involves the anterior floor via the endonasal side. The bony anterior stage separates the brain with the meninges from the face including the sinuses, nasal cavities and eyes. Anterior-stage bone is extremely thin over the eyes (1-2 millimeters thick), and even has holes in the cribiform plate of the ethmoid to allow olfactory nerve fibers to pass into the nose. In the middle and in front, the bone is the ethmoid, in the middle and on the sides behind, the bone is the sphenoid, and on the sides in front, the bone is the frontal.
Endonasal osteomeningeal breaches have 2 possible origins:
- Traumatic: most frequent
- Spontaneous: the rarest
Traumatic osteomeningeal breaches
In the event of severe traumatic fractures involving the face, such as car accidents, sports accidents (skiing, horseback riding, etc.) or falls, a bone breach may occur. In addition to the usual haematomas, haemosinus (blood in the sinuses) and deformities, there may be a flow of cerebrospinal fluid through the nose, which is not always perceived by the patient. When the patient feels this discharge, it may correspond to a sweet taste in the mouth. The breach, which is a bony opening, represents an unusual entry point to the meninges for commensal (usual) germs from the nose, exposing the patient to the risk of meningitis. Diagnosis is often obvious from a CT scan of the face.
Management is the responsibility of the maxillo-facial surgeon, the ENT specialist and, if necessary, the neurosurgeon. An operation is not always necessary for cerebrospinal fluid drainage, which can stop spontaneously.
Spontaneous osteomeningeal breaches
Identification of these breaches is frequently more difficult despite CT scans with millimetric bone sections, as they are often very small. T2 MRI with fat saturation is useful, in particular to look for signs of cerebrospinal fluid hyperpressure (e.g. empty sella turcica, dilatation). Drainage is unilateral (from a single nostril), fluctuating and sometimes intermittent, with pauses lasting several months. The use of fluorescent tracers or contrast media injected intra-thecally (trans meningeally) is no longer possible in France, to identify and locate them. However, it is possible to collect the fluid flowing through the nose on one side only, and look for Beta 2 transferrin or beta trace in it, to be certain that it is indeed cerebrospinal fluid (rather expensive assay). The classic patient profile is: 40-50 years old, overweight, high blood pressure, hormonal disorders, but this is not systematic. Management varies from case to case (abstention, diamox©, intervention).
Endonasal osteomeningeal breaches are a risk factor for meningitis, and patients should be vaccinated against the germs most frequently implicated: Pneumococcus and Haemophilus influenzae.
Indications and objectives of endonasal breach closure
Endonasal breach closure concerns adults with an identified, persistent endonasal breach, but also adults with a persistent endonasal breach complicated by meningitis.
Endonasal breach closure should be performed in cases of :
- Nose that runs continuously or intermittently, with a very clear, transparent liquid as thin as water, on one side only, spontaneously or during effort (the contracted abdomen increases the pressure of the cerebrospinal fluid) through one nostril and into the throat (anterior and posterior rhinorrhea).
- Signs of meningitis with authenticated endonasal breach. Closure will take place after the meningitis has healed, if necessary. Indeed, if we’re lucky, meningitis can lead to local scarring fibrosis, which obstructs the breach. Meningitis is diagnosed by lumbar puncture. Clinical signs suggestive of meningitis include severe headache, stiff neck, discomfort with light (photophobia) and noise (phonophobia), nausea and vomiting, and extreme fatigue (asthenia).
Objectives of endonasal breach closure are:
- Stop the flow of cerebrospinal fluid.
- Reduce the risk of meningitis and empyema (brain abscess).
The different stages of the intervention
The surgical procedure
Under general anaesthetic in the operating theatre, the sinus is opened and emptied, the breach is identified if possible and exposed as best as possible, biological glue and a natural patch of fat taken from the abdomen or tendon taken from the thigh (fascia lata) are placed at the site of the breach. The graft is held in place by absorbable strands and a flexible silicone arch. This flexible support arch is removed after 15-21 days under local anaesthesia.
Post-surgery recovery period
The patient usually returns home after 3 days in hospital.
You will need to lie down for the first 24 hours to limit pressure, and a specific medication to lower cerebrospinal fluid pressure may be prescribed for a few days.
After hospitalization, you should remain at home for 21 days, resting and checking for nose or throat bleeding and hematoma at the donor site.
The surgeon will give you one month’s leave from work if necessary.
Pressure sports are not recommended for the first 2 months, and resumption should be gradual.
Pain is moderate, mainly in the donor site. It is controlled by class I or II analgesics.
Post-operative care at home: humidification of the nose with very mild saline, without pressure. Nosewash should be gentle, but should only be started after 4 days.
Scar: On the donor site (abdomen in the umbilicus, barely visible, or on the side of the thigh over 7 cm), but none on the face.
Complications associated with endonasal breach closure
In addition to the risks inherent in any surgery involving general anaesthesia, endonasal breach closure presents rare complications:
- Nasal haemorrhage (epistaxis) after the procedure, very minor.
- Infection.
- Nasal scabs.
- Bridles responsible for limiting nasal flow.
Exceptional complications are what make this operation so difficult, but they can be managed with experience and technical instruments such as neuronavigation:
- Compressive intra-orbital hematoma.
- Double vision (diplopia).
- Blindness.
- Meningitis.
Persistent discharge of cerebrospinal fluid does not constitute a complication, but rather a failure of the graft. Meningitis is not a complication, but a consequence of the existing osteomeningeal breach.
Please refer to the ENT College’s explanatory sheet on endonasal osteomeningeal breach closure for further explanations:
Frequently asked questions
Here is a selection of questions frequently asked by Dr Delagranda’s patients during consultations for endonasal breach closure in La Roche-sur-Yon.
Is surgery compulsory?
Yes, once the indication has been confirmed, as meningitis and brain abscesses (empyema) are significant risks associated with breaches.
Is the effect guaranteed?
No, it depends on the graft’s acceptance and viability. Grafting is effective in the vast majority of cases.
Is the effect long-lasting?
Yes.
Is it painful?
Very little, but more at the donor site than in the nose.
Fees and coverage of the procedure
Endonasal breach closure is covered by health insurance. Contact your mutual insurance company to find out whether any extra fees will be covered.
Do you have a question? Need more information?
Dr. Antoine Delagranda is available to answer any questions you may have about endonasal breach closure. Dr Delagranda is a specialist in ENT surgery at the Clinique st-charles in La Roche sur Yon.
ENT consultation for endonasal breach closure in Vendée
Dr Antoine Delagranda will be happy to answer any questions you may have about endonasal breach closure surgery. Dr Delagranda is a specialist in ENT surgery at the Clinique Saint Charles in La Roche-sur-Yon in the Vendée.