The endoscopic repair of frontal sinus CSF leaks is rarely possible because of reduced access and visibility. Only small defects of the area that can be seen bulging anteriorly when the frontal recess has been opened can be dealt with endoscopically. If there is a lateral defect in the posterior wall of the frontal sinus, this can be dealt with via an extradural approach, minimizing the risk of intracranial complications (Fig. 15.21 a-d). Usually a coronal flap with removal of the anterior wall of the frontal sinus allows access to the defect. The pericranium is best preserved and replaced over the bone, which is reattached with miniplates, as trying to swing a bone flap down on attached periosteum usually results in tearing it and it is then of little use. The site of the defect can then be defined and repaired with fascia and fat to hold the graft a
Fig. 15.18 a A defect in the cribriform plate. Fascia was placed above it. b Fascia overlay over the defect. c Endoscopic appearance of the CSF leak repair at 3 years.
c in position. If there is severe disruption of the frontal recess, then the frontal sinus is obliterated with fat (it is imperative to remove all underlying sinus mucosa and to drill the bone that is covered by mucosa with a diamond drill in order to avoid leaving any residual mucosa that could lead to the formation of a muco-cele) (Weber et al., 1999).
ally into the pterygoid plates; defining its edges is then not easy. In these cases it helps to remove the root of the medial pterygoid plate. In order to do this, the sphenopalatine artery has to be exposed and di-athermied. It is important to freshen the edges of any defect before placing a graft, as this seems to be an important part in initiating the repair process.
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