Fossa Defect Research Articles

Middle Fossa Approach to a Temporosphenoidal Encephalocele -Technical Note-

Temporosphenoidal encephalocele (TSE) is a rare entity caused by herniation of the anteromedial temporal lobe into the sphenoid sinus (SS) through a middle fossa (MF) defect. A 45-year-old woman presented with a spontaneous TSE manifesting as a 4-year history of recurrent cerebrospinal fluid rhinorrhea and meningitis. Coronal computed tomography showed a skull defect in the superior wall of the right lateral recess of the SS. This homogeneous intrasphenoidal lesion appeared hypointense on T(1)-weighted magnetic resonance (MR) imaging and hyperintense on T(2)-weighted MR imaging. The patient underwent a frontotemporal craniotomy and extradural MF exploration. The encephalocele was amputated and the temporal base dura primarily sutured and reinforced with fat graft. The MF hole was plugged with temporalis fascia and a calvarial graft layered over the bone defect. Histological examination confirmed meningoencephalocele. Rhinorrhea resolved and the patient remained asymptomatic. Resection of an anteromedial TSE and closure of the craniodural defect in the MF floor via a less invasive extradural skull base approach is effective.

Malignant Peripheral Nerve Sheath Tumor of the Hand

Sir: The popliteal fossa defect is a rare and difficult-to-treat condition. The great mobility and the proximity to important lower extremity vessels are aspects to consider. Diverse techniques have been described to treat this defect, such as muscle flaps,1 fasciocutaneous flaps,2 free flaps,3 split-thickness grafts, allografts, and expanders,4 with these last ones being used most frequently for burns and trauma sequelae. There are few techniques that provide primary closure of this area; rotation flaps are a good option that give good-quality scars. The purpose of this article is to report our experience with closure of popliteal fossa defects using the fasciocutaneous cone flap that we had described previously.5 Clinical data were obtained from patients with unique or associated popliteal fossa defects who underwent reconstruction with a fasciocutaneous cone flap at the Hospital del Trabajador in Santiago, Chile, between 2000 and 2007. There were five patients included in the study, all of whom were men with a mean age of 37.4 years (range, 26 to 47 years). The injury mechanism was trauma: two vehicle accident injuries, two work-related injuries, and one sports-related injury. The mean defect length was 11.6 cm (range, 8 to 20 cm), compromising deep structures. Two of them had associated vascular injury. All patients underwent reconstruction with a fasciocutaneous cone flap, which consists of a rotation flap covering the defect and a V-Y advancement flap toward the donor area. The patients with vascular compromise required a previous vessel repair. There were three dehiscences in the proximal portion of the rotation flap that required resuture. The patients were discharged at a mean of 24.2 days (range, 8 to 38 days) after the fasciocutaneous cone flap operation. There are few publications concerning the coverage of popliteal fossa defects. Our results using the fasciocutaneous cone flap have solved this problem, with acceptable complications. The cone flap provided a good-quality coverage that allowed normal functionality of the lower limb in the long term. The importance of this report is to present an alternative for the closure of popliteal fossa defects in only one operation, with excellent functional and aesthetic results (Figs. 1 through 3).Fig. 1.: Popliteal defect measuring 15 × 8 cm.Fig. 2.: Repair with the fasciocutaneous cone flap.Fig. 3.: Final result.Wilfredo Calderón, F.A.C.S. Sergio Llanos, M.D. Rodrigo Villagrán, M.D. Rocío Las Heras, M.D. Daniel Calderón Burns and Plastic Surgery Department Hospital del Trabajador de Santiago Santiago, Chile

Covering the Popliteal Fossa Defect with the Fasciocutaneous Cone Flap

Covering the Popliteal Fossa Defect with the Fasciocutaneous Cone Flap

Reconstruction of Nonhelical Auricular Defects with Local Flaps

The integrity of each of the components of the auricle is important for its overall aesthetic appearance. Cartilage-exposing nonhelical defects that are too large to be closed primarily without distorting the auricle may be reconstructed with local flaps. The objective was to present our experience with the reconstruction of nonhelical medium-sized defects using a variety of simple, one-stage local flaps. Eighteen patients who underwent reconstruction of nonhelical auricular defects with local flaps at our center from 2003 to 2006. Defect size ranged from about 10 to 20 mm. Various methods were used for reconstruction as follows: conchal defect (n=11)--pull-through postauricular flap or cutaneous rotation flap from the concha itself; triangular fossa defect (n=3)--transposition-rotation flap from the concha or cutaneous periauricular pull-through flap via the root of the helix; antihelical defect (n=2)--V-Y advancement flap from the skin of the antihelix; and tragus defect (n=2)--periauricular cutaneous flap. All flaps survived. Transient congestion was noted in four patients. The aesthetic results were good, with no auricular deformation. It is important that reconstructive surgeons be familiar with a variety of basic flaps for reconstruction of nonhelical defects. An algorithm for nonhelical flap reconstruction is suggested.

How To Prevent Intracranial Infection in the Anterior Skull Base with Simultaneous Nasal Cavity Surgery

In anterior central skull base resections or in trauma, old or new, there may well be direct connection with the nasal cavity. To provide absolute protection against ascending infection, any closure must be as watertight as possible. It is also essential that it be vascularized. The galeofrontalis myofascial flap is based on the central supranasal, supraorbital region. The blood supply has been studied and published. Based inferiorly, this can cover almost any anterior fossa defect, it overlaps the danger area, it can be fixed with sutures through drill holes, and the frontal lobe provides superior pressure. It is a water- and CSF-tight solution, and has not failed us in tumor, trauma, or deformity cases.

Morphogenetic Differences of Secundum Atrial Septal Defects

It is generally considered that the development of secundum atrial septal defect (ASDII) or oval fossa defect is the result of excessive resorption of the embryological atrial septum primum, but this does not seem to explain all defects. We investigated 58 postmortem hearts with an ASDII and 22 normal hearts from patients ranging in age from 1 day to 49 years. The different structures of the oval fossa were examined. In 86% of the specimens, the defects were the result of a malformation of the valvula foraminis ovalis or embryological atrial septum primum, and in 14% an absent superior limbus (septum secundum) was the cause of the interatrial communication. The "septum primum" ASDs were divided into four subgroups based on the degree of deficiency of the septum primum and position of the ostium secundum within the septum primum. We conclude that the morphogenesis of ASDII is variable and both septum primum and septum secundum defects occur, which may be relevant in view of genetic studies that may lead to further differentiation of patients with and without genetically determined ASDIIs.

Spontaneous CSF rhinorrhoea secondary to a middle cranial fossa defect.

Spontaneous cerebrospinal fluid rhinorrhoea is a clinical entity that is difficult to both diagnose and treat. A case in a 56-year-old woman with a defect in the lateral wall of the sphenoid sinus and middle cranial fossa floor is presented. Pathogenesis and management of this rare condition are discussed. Copyright 1999 Harcourt Publishers Ltd.

The indications and outcomes in the use of osteocutaneous radial forearm free flap.

Whether secondary to cancer surgery ablation or trauma, surgeons are faced with defects of the mandible or maxilla that would be best reconstructed with a thin, pliable soft tissue component and vascularized bone. A subset of these challenging wounds do not require the bicortical bone necessary to reestablish structural integrity or to retain a dental prosthesis, because the soft tissue needs are more critical than the bony needs. It is this niche that the radial forearm osteofaciocutaneous free flap (RFOFF) fulfills well. In the past, potential and real donor site morbidity has precluded the routine use of this flap. New methods to reduce this morbidity have rekindled our use of this flap. PROCEDURES USED: A retrospective review of patients with defects of the mandible or maxilla treated with the RFOFF from July 1, 1997, to December 31, 2000, was performed. After flap harvest, the donor site was rigidly fixated. A skin graft was placed, and a volar splint was applied for 7 days. The arm was then fully mobilized. Parameters examined were defect location, donor site complications, flap survival, fistula occurrence, plate fracture, and/or extrusion. Thirty-four patients were reconstructed with the RFOFF with a follow-up of 10-54 months. Seven patients had an anterior maxillectomy defect, and 27 patients had a lateral mandibulectomy defect with associated tongue/tonsillar fossa and/or palate defect. There were no cases of flap failure or donor site radius fracture. During the follow-up period, there were no plate fractures or intraoral exposures as evidenced by clinical and radiographic evaluation. Fistulas occurred in five patients; all healed without surgical intervention. With rigid fixation of the residual radius, donor site morbidity has been minimized, and indications for this flap have expanded. Specifically the anterior maxillary arch and the ascending ramus, angle, and posterior body of the mandible (nontooth-bearing areas) are the sites most amenable to the thin bony stock of the harvested radius. The pliable forearm skin is ideal for the soft tissue defects. We believe that the RFOFF with bone has a definite role in the reconstruction of select head and neck defects.

Sphenoid encephaloceles: disease management and identification of lesions within the lateral recess of the sphenoid sinus.

Encephaloceles usually involve herniation of frontal lobe tissue through an anterior cranial fossa defect into the ethmoid sinus or nasal cavity. Encephaloceles can also result from temporal lobe herniation through a middle fossa defect into the sphenoid sinus. Within the sphenoid, encephaloceles are thought to occur most commonly in the central or midline aspect of the sinus. Lateral sphenoid encephaloceles, especially within the lateral aspect of the sphenoid sinus when the sphenoid sinus has pneumatized extensively into the pterygoid recess, are considered exceedingly rare. The objectives of the study were to review our experience with sphenoid encephaloceles to understand the relative frequency and the locations in which they occur within the sphenoid sinus and to report our experience in caring for patients with this condition. Retrospective review. Retrospective review of patient records and operative reports from 1991 to 2000. RESULTS Twelve patients were treated for intrasphenoid encephaloceles during a 10-year period. Eight patients had lesions located in the lateral recess of the sphenoid sinus. Surgical repair was undertaken in all 12 cases using endoscopic techniques. In 11 of 12 cases, the repair was successful with follow-up times of 12 to 69 months (mean follow-up, 31.9 mo). Temporal lobe encephaloceles in the lateral sphenoid sinus have been reported rarely in the literature. Careful preoperative evaluation and localization of the sphenoid defect are critical for the selection of the optimal surgical approach for repair of the skull base defect. Our 10-year experience represents the largest group of patients treated endoscopically for intrasphenoid encephaloceles reported to date.

Alloplastic reconstruction of a temporal bone and glenoid fossa defect

Alloplastic reconstruction of a temporal bone and glenoid fossa defect

Spontaneous CSF rhinorrhoea secondary to a middle cranial fossa defect

Spontaneous cerebrospinal fluid rhinorrhoea is a clinical entity that is difficult to both diagnose and treat. A case in a 56-year-old woman with a defect in the lateral wall of the sphenoid sinus and middle cranial fossa floor is presented. Pathogenesis and management of this rare condition are discussed.

Fossa navicularis disruptions in adolescent sexual assault victims

Background Adolescent females have typically comprised a significant portion of the total population of patients seen for medical-legal exams by the SART team. Recent studies have documented the correlates of injury in sexual assault victims and noted the frequency of injury to the fossa navicularis in both adult and adolescent victims of sexual assault. Methods A retrospective case review inclusive of the history, physical exam and colposcopic photographs of 136 adolescents seen between January, 1990 through December, 1994 was conducted. Colposcopy at 15 X was utilized. Six cases were eliminated from inclusion due to inadequacy of the photodocumentation. Patients were seen after sexual assault, molest or consenting intercourse with a minor. 69(53%) of the 130 were found to have positive fossa findings. The nature of positive fossa findings was divided into two time frames: 1.) acute/resolving acute fossa trauma and 2.) old/non-acute fossa disruptions. Results 69 females had positive fossa findings. Their mean age was 14.8 y.o. 65% (45/69 had old fossa disruptions. 35% (24/69) had fossa trauma that was either acute or resolving. The range of time to exam was from less than 24 hrs. to 30 days. 29% of the acute group (7/24) were examined in less than 24 hrs. Another 29% received evaluation within 72 hours. Overall, 79% of this acute group received an exam within 2 weeks of the assault (19/24). In the positive fossa group, these factors were documented: history of penile/vaginal contact 62% (43/69); history of pain: 74% (51/69); post-assault bleeding: 29% (20/69); history of prior victimization: 33 1/3% (23/69) and acknowledgement of prior consenting sexual activity: 48% (33/69). In 62% (43/69), genital trauma to sites other than the fossa navicularis was present. In this sample, 26% (18/69) returned for a follow-up exam, which included colposcopy to document the overall resolution of trauma. Of the 24 cases with acute or resolving fossa trauma, 66.6% (16/24) returned for follow-up. In 100% of these cases, the fossa defect persisted on follow-up exam. Conclusions in 130 females adolescents evaluated using colposcopy during a 5 year period, fossa defects were present in 53%. These were associated with penile-vaginal contact, pain, bleeding, prior vaginal penetration and other genital trauma. Acute and resolving/acute fossa defects noted on initial exam persisted in 100% of the cases which returned for follow-up exam, representing a persistent, post-traumatic disruption to this structure. Adolescent females have typically comprised a significant portion of the total population of patients seen for medical-legal exams by the SART team. Recent studies have documented the correlates of injury in sexual assault victims and noted the frequency of injury to the fossa navicularis in both adult and adolescent victims of sexual assault. A retrospective case review inclusive of the history, physical exam and colposcopic photographs of 136 adolescents seen between January, 1990 through December, 1994 was conducted. Colposcopy at 15 X was utilized. Six cases were eliminated from inclusion due to inadequacy of the photodocumentation. Patients were seen after sexual assault, molest or consenting intercourse with a minor. 69(53%) of the 130 were found to have positive fossa findings. The nature of positive fossa findings was divided into two time frames: 1.) acute/resolving acute fossa trauma and 2.) old/non-acute fossa disruptions. 69 females had positive fossa findings. Their mean age was 14.8 y.o. 65% (45/69 had old fossa disruptions. 35% (24/69) had fossa trauma that was either acute or resolving. The range of time to exam was from less than 24 hrs. to 30 days. 29% of the acute group (7/24) were examined in less than 24 hrs. Another 29% received evaluation within 72 hours. Overall, 79% of this acute group received an exam within 2 weeks of the assault (19/24). In the positive fossa group, these factors were documented: history of penile/vaginal contact 62% (43/69); history of pain: 74% (51/69); post-assault bleeding: 29% (20/69); history of prior victimization: 33 1/3% (23/69) and acknowledgement of prior consenting sexual activity: 48% (33/69). In 62% (43/69), genital trauma to sites other than the fossa navicularis was present. In this sample, 26% (18/69) returned for a follow-up exam, which included colposcopy to document the overall resolution of trauma. Of the 24 cases with acute or resolving fossa trauma, 66.6% (16/24) returned for follow-up. In 100% of these cases, the fossa defect persisted on follow-up exam. in 130 females adolescents evaluated using colposcopy during a 5 year period, fossa defects were present in 53%. These were associated with penile-vaginal contact, pain, bleeding, prior vaginal penetration and other genital trauma. Acute and resolving/acute fossa defects noted on initial exam persisted in 100% of the cases which returned for follow-up exam, representing a persistent, post-traumatic disruption to this structure.

Association of spontaneous anterior fossa CSF rhinorrhea and congenital perilymphatic fistula in a patient with recurrent meningitis

A case of recurrent meningitis associated with spontaneous cerebrospinal fluid (CSF) rhinorrhea and left, sensorineural hearing loss in a 4-year-old boy was found to be due to simultaneous congenital defects. High resolution CT examination clearly showed an anterior fossa defect and an inner ear malformation, including demineralization in the region of the footplate of the stapes, and this provide clear guidance for the surgeon.

Association of spontaneous anterior fossa CSF rhinorrhea and congenital perilymphatic fistula in a patient with recurrent meningitis

A case of recurrent meningitis associated with spontaneous cerebrospinal fluid (CSF) rhinorrhea and left sensorineural hearing loss in a 4-year-old boy was found to be due to simultaneous congenital defects. High resolution CT examination clearly showed an anterior fossa defect and an inner ear malformation, including demineralization in the region of the footplate of the stapes, and thus provided clear guidance for the surgeon.

Intractable complex partial seizures associated with occult temporal lobe encephalocele and meningoangiomatosis: A case report

Occult congenital temporal lobe encephalocele has rarely been reported in association with medically intractable complex partial seizures. The four previously reported cases were unsuspected preoperatively. We present the case of an 18-year-old woman with intractable complex partial seizures since age 13. Seizure onset was electrically localized to the right temporal lobe. Preoperative neuroimaging studies revealed a middle fossa defect and inferior herniation of the right temporal lobe. Pathologic examination of the resected encephalocele revealed prominent features of meningoangiomatosis. We believe this to be the first case of temporal lobe encephalocele and epilepsy to be diagnosed preoperatively, and the first case also to be associated with meningoangiomatosis. The relevant literature on meningoangiomatosis and on temporal lobe encephalocele as a cause of epilepsy is reviewed.