The Role of Endonasal Endoscopic Skull Base Repair in Posttraumatic Tension Pneumocephalus

Abstract

Objectives: Information about the endonasal endoscopic approach (EEA) for the management of posttraumatic tension pneumocephalus (PTTP) remains scarce. Concomitant rhinoliquorrhea and posttraumatic hydrocephalus (PTH) can complicate the clinical course. Methods: The authors systematically reviewed pertinent articles published between 1961 and December 2020 and identified 6 patients with PTTP treated by EEA in 5 reports. Additionally, the authors share their institutional experience including a seventh patient, where an EEA resolved a recurrent PTTP without rhinoliquorrhea.Results: Seven PTTP cases in which EEA was used as part of the treatment regime were included in this review. All cases presented with a defect in the anterior skull base, and 3 of them had concomitant rhinoliquorrhea. A transcranial approach was performed in 6/7 cases before EEA was considered to treat PTTP. In 4/7 cases, the PTTP resolved after the first intent; in 2/ 7 cases a second repair was necessary because of recurrent PTTP, 1 with and 1 without rhinoliquorrhea, and 1/7 case because of recurrent rhinoliquorrhea only. Overall, PTTP treated by EEA resolved with a mean radiological resolution time of 69 days (range 23-150 days), with no late recurrences. Only 1 patient developed a cerebrospinal fluid diversion infection probably related to a first incomplete EEA skull base defects repair. A permanent cerebrospinal fluid diversion was necessary in 3/7 cases. Conclusions: Endonasal endoscopic approach repair of air conduits is a safe and efficacious second-line approach after failed transcranial approaches for symptomatic PTTP. However, the strength of recommendation for EEA remains low until further evidence is presented.

Traumatic tension pneumocephalus: a case report and perspective from Indonesia

“…Recent studies have explored various endoscopic techniques that simultaneously address the resolution of traumatic tension pneumocephalus (TP) and the closure of the bone defect responsible for cerebrospinal fluid leakage in a single surgical stage (6,7). The development of new techniques and more angulated instruments for endoscopic surgery has increased the possibility of accessing more challenging endonasal areas (8).…”

Iatrogenic tension pneumocephalus complication of osteoradionecrosis in the treatment of nasopharyngeal carcinoma. A case report and critical literature review

“…[18,19] PN is commonly associated with various events such as post-craniotomy or surgical interventions, barotrauma, ear infections, exposure to nitrous oxide or induced nitrogen anesthesia, and diagnostic procedures (e.g., lumbar puncture). [20,21] While the location of PN may vary, it typically manifests with the presence of air in the apical space and encompasses intraventricular, intraparenchymal, subarachnoid, subdural, and epidural areas.…”

“…Despite significant advances in understanding the pathophysiology of PN, the documentation remains limited, with only six confirmed cases of PN and only four cases of TPN properly documented regarding patients with NPC. [19][20][21] Several mechanisms have been identified to explain the occurrence of TPN, with barotrauma being one of the most studied. In this regard, Kankane et al (2016) reported the case of a 50-year-old man who developed TPN due to high air pressure (hyperbaric) following epidural steroid injections for the treatment of cervical radiculopathy.…”

Transnasal Endoscopic Treatment of Tension Pneumocephalus Caused by Posttraumatic or Iatrogenic Ethmoidal Damage

“…In a recent literature review, Dalolio et al described the endoscopic endonasal approach as an effective second-line treatment of symptomatic posttraumatic TP [ 15 ]. Li et al [ 9 ] reported 26 cases of TP caused by endoscopic endonasal surgery collected in an English literature review: 11 cases were caused by an ethmoidal defect, and the therapeutic approach was based on a defect multilayer closure with or without craniotomy.…”