Use of Coblator for Endoscopic Resection of a Frontoethmoid Encephalocele

We present the case of a 54-year-old African female who presented to the Montefiore Medical Center Emergency Department with a several day history of headache, fever, nuchal rigidity, and photophobia. She was admitted with a presumed diagnosis of meningitis. An MRI of the brain with intravenous contrast revealed a large frontoethmoid encephalocele extending to the left nasal cavity (Image 1).

CT scan was obtained which revealed a large left frontoethmoidal encephalocele extending to the nasal cavity with likely postobstructive opacification of the left maxillary and frontal sinuses (Image 2). After treatment with intravenous antibiotics, the patient clinically improved and several days later underwent resection and repair of the encephalocele.

A lumbar drain was placed preoperatively with intrathecal injection of fluorescein. Nasal endoscopy revealed herniated tissue in the left nasal cavity from the middle meatus and extending to the floor of the nasal cavity. Using a combination of the endoscopic bipolar electrocautery as well as extensive use of Coblator, the encephalocele was reduced. This was achieved without difficulty or complication. After resection, the patient was noted to have a 12 by 12 mm defect of the anterior skull base just posterior to the anterior ethmoid artery. This was repaired in layered fashion using a DuraMatrix underlay, a free mucosal graft obtained from the right inferior turbinate, Surgicel, DuraSeal, and gelfoam. Image 3 reveals resection of the encephalocele with the Coblator, with the green dye representing CSF stained with fluorescein. After the repair, there was noted to be no further leakage of CSF.

The patient had an uneventful postoperative course with the lumbar drain being removed on POD 3. She recovered without any neurologic deficits or signs of CSF leak and was discharged on POD 6. At 2- and 6-week follow-up, the patient was without any symptoms of meningitis or rhinorrhea. Nasal endoscopy revealed normal postoperative appearance of the defect repair site, with no apparent leakage, and healthy appearing mucosa.

A literature search reveals one prior series by Smith et al of Coblator use for resection of encephalocele. As its usage continues to broaden among surgical fields and within otorhinolaryngology, the Coblator appears to be a safe alternative to bipolar for resection of encephalocele, and we found this likely reduced our operative time significantly without bleeding or other complications.