Patient with unilateral hearing loss, rhinorrhoea, and eye discharge. 

Diagnosed with CSF meningoencephalocoele on CT. For craniotomy and resection.

Background

• Respiratory disease
  • Asbestosis and COPD
  • FEV1 <40%, FVC 70%, DLCO 40%
  • CAP 2021 -> prolonged ventilation in ICU
  • Recurrent pneumothoraces requiring talc pleurodesis 2017. Postoperative delirium/POCD and CO2 retention requiring re-intubation.
  • TTE ’21 – nil cor pulmonale. 

• HCV + but no viral load. Spontaneously cleared?
• 4WW, independent with ADLs

Issues

• Severe respiratory disease
  • Recent antibiotics and steroids 
  • Hyperinflated in clinic, SpO2 92%. Chest clear and expiratory phase normal.
  • BODE 4 (60% mortality at 52mths)
  • Gold class 3B

Discussion

• What is a skull base meningoencephalocoele?
  • Rare
  • Occur after head trauma (relevant for this man), can be congenital or rarely reported to develop secondary to benign intracranial hypertension. 
  • Trans-sphenoidal, transethmoidal, spheno-orbital, sphenoethmoidal or sphenomaxillary.
  • Commonly present with nasal obstruction, CSF rhinorrhoea, intranasal polyps, recurrent meningitis, and headaches. 
  • Often combined approach, with neurosurgeons and ENT.
  • Treated with endoscopic trans-nasal approach (good access to skull base) or with open surgery.
  • Case report: https://casereports.bmj.com/content/13/5/e234703

• 

Picture shows transethmoidal meningoencephalocoele

• Opportunities for optimisation?
  • Recent abx and steroids were in preparation for this surgical episode. Further delay to OT unhelpful.
  • Patient at high risk of postop pulmonary complications and ventilation 
  • Optimised.

• Alternatives to surgery?
  • No

Plan:

• ICU 3, assuming nil intraoperative complications
• Proceed to OT
• Lung protective ventilation strategies given likely severe bullous disease. 
• Risk of tension pneumothorax intraoperatively.