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TITLE: CSF RHINORRHOEA SECONDARY TO

MAYFIELD HEAD CLAMP

Authors Mr Ioannis Moumoulidis (MRCS), Miss Helen Fernandes (FRCS), Mr Ran De (FRCS)

Institution Department of Neurosurgery / Otolaryngology

University of Cambridge

Addenbrookes NHS Trust

Cambridge CB2 2QQ

United Kingdom

Address for correspondence

Mr I Moumoulidis

36 Moorhouse Way

Kettering

Northants, NN15 7LX

United Kingdom

Tel: 07711 384981

E-Mail: moumoulidis@aol.com

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Abstract

We report a unique case of frontal sinus fracture and Cerebral-Spinal Fluid (CSF) leak

due to the Mayfield head clamp screws used during a frontal craniotomy and debulking

of glioblastoma multiforme. The CSF leak settled with conservative management and no

intervention was necessary. Clinicians therefore need to be aware that in patients with

large frontal sinuses such a complication is possible.

Keywords: Mayfield head clamp, Craniotomy, Complication, Frontal sinus fracture

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INTRODUCTION

Many neuro-surgical procedures may require the head to be firmly supported so that

pressure can be applied without the danger of any movement. During intracranial

microsurgical procedures, the Mayfield head holder is widely used for head-fixation. We

report a case of a frontal sinus fracture and Cerebral-Spinal Fluid (CSF) leak following

application of a Mayfield head holder during a frontal craniotomy.

CASE REPORT

A 70 year-old male was admitted to the hospital with increasing headaches and left sided

weakness. He had been started on Dexamethasone in the hospital with complete

resolution of his symptoms. Neurological examination was unremarkable. A CT followed

by an MRI showed a craggy looking heterogeneously enhancing lesion in the right

fronto-parietal lobe, very suspicious of a malignant intrinsic brain tumour (Fig 1). He was

keen to pursue full and active treatment, so he underwent right frontal craniotomy for

biopsy and debulking of the lesion. During the procedure, the patient was in supine

position, with his head turned 450 to the left and firmly stabilized by the Mayfield head

clamp. These were applied in the usual fashion tightened to forehead and occipital area.

At the end of the procedure, the pin sites were examined. The skin overlying the pin site

on the forehead was slightly depressed and was oozing blood. This was controlled with

4.0 Ethilon suture. The procedure was uneventful and histological findings confirmed a

glioglastoma multiforme.

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Five days post procedure, the patient developed CSF rhinorhoea from his left nostril. The

CSF leak was confirmed by the presence of ß2 transferrin. An urgent CT scan was

performed which showed CT scan showed large frontal sinuses, and an associated

fracture with a displaced bony defect in the anterior table of the left frontal sinus (Fig 2a)

and a small breach of the inner table (Fig 2b). There was a fluid level in the left frontal

sinus and partial opacification of the left frontal recess. He was managed conservatively

with a lumbar drain and the CSF leak resolved spontaneously at 5 days post drain. The

patient was discharged from hospital after 10 days without any further sequelae.

DISCUSSION

Fronto-parietal craniotomies are one of the commoner neurosurgical approaches. The

Mayfield head clamp is a well-established method for firmly stabilizing the head during

neurosurgery (Fig 3). This device can effectively secure the cervical spine and head

without restricting surgical access. Extreme care must be used in positioning the

Mayfield head holder screws. Scalp pins are positioned in such way to assist exposure of

the operative field and to avoid important anatomical structures. Usually they are

tightened to 60lbs/sq inch. 1

Some of the complications from this device include systemic and intracranial

hypertension, venous air embolism, skin necrosis, scalp laceration, loosening of the pins

and the head slipping out of the clamp 2,3. Other complications relate to the depth of the

intracranial structures penetrated, such as extradural hematoma and meningitis have been

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documented 4. Two cases of venous air embolism5 and a case of unilateral blindness6

have also been documented whilst using the Mayfield head holder.

We describe another potentially dangerous complication due to the Mayfield head clamp.

In our case the patient had well developed frontal sinuses. Fracture of the frontal sinuses

can be managed conservatively or surgically depending on the degree of displacement of

the fragments and the presence of complications, such as CSF leak. Uncomplicated

fractures with minimal displacement of the inner table and intact sinonasal mucosa do not

require treatment per se7. If however there is significant displacement of a fragment

within the inner table with its associated risk of epilepsy, surgical management is

essential 8. In the presence of CSF leakage for more than 7-10 days, there is a significant

risk of infections such as meningitis 9.

Management of inadvertent injury to the frontal sinus is a controversial when the sinus

mucosa is injured. Some surgeons prefer total mucosal exenteration, followed by

irrigation, packing with antibiotic soaked gel foam and placement of a pericranial graft

over the frontal recess 10. Others may treat it with an osteoplastic flap and obliteration 11.

However, in some cases where the mucosa is damaged, conservative management was

equally effective.

This is the first case been reported in the literature describing fracture of both, the inner

and outer tables of the frontal sinus following use of the Mayfield head clamp. Therefore

there is no urgent need to alter our practice. However, we suggest that if possible the

screws should be placed higher up on the skull above the surface landmarks of the frontal

sinuses whenever possible. Neurosurgeons can review preoperative CT scans to assess

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the anatomy of the skull including pneumatisation of the frontal sinus. We recommend

that if on CT scan the frontal sinuses appear to extend to a higher level, (see figure 4),

then a plain X-ray or coronal views on CT may delineate the size and extent of these

frontal sinuses. This may help to prevent inadvertent injury to the frontal sinus. It is also

important that surgeons are aware of CSF rhinorrhoea postoperatively and consider

investigations on an urgent basis.

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REFERENCES

1. Schroder J. Variable attachment for the Mayfield head rest to fit on a Halo ring in

the surgery of cervical spine injuries. Neurosurg Rev 1999; 22(1): 62-64

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160-1

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JM. Conrtalateral extradural hematoma following craniotomy for traumatic

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with removal of the Mayfield skull clamp. Anesth Analg 1995; 80(5):1049-50

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penetration. Laryngoscope 1978; 88:225-232

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Compound anterior cranial base fractures: classification using computerized

tomography scanning as a basis for selection of patients for dural repair. J

Neurosurg 1998; 88:471-77

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10. Stevens M, Kline SN. Management of frontal sinus fractures. J Craniomaxillofac

Trauma 1995;1(1): 29-37

11. Petruzzelli GJ, Stankiewicz JA. Frontal sinus obliteration with hydroxyapatite

cement. Laryngoscope 2002; 112(1): 32-6

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LEGENDS

Figure 1. Axial CT scan of the head. Obvious tumour in the right fronto-parietal lobe

with surrounding oedema, distortion of lateral ventricles and midline shift. Frontal

sinuses appear prominent.

Figure 2. Axial CT of the head on bone settings.

2 a) - Shows a fracture of the outer table of the skull and displacement of the

fragment. There is also opacification of the left frontal sinus.

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2 b) - there is a small fracture of the inner table of the skull and opacification of

the left frontal sinus.

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Figure 3. Picture of the Mayfield head clamp.

Figure 4. Coronal CT scan of sinuses on bone settings. Obvious well developed frontal

sinuses (also note right sided deviated septum, right concha bullosa and widened frontal

recess.