Patient with unilateral hearing loss, rhinorrhoea, and eye discharge.
Diagnosed with CSF meningoencephalocoele on CT. For craniotomy and resection.
- 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
- 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
- What is a skull base meningoencephalocoele?
- 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
- Alternatives to surgery?
- ICU 3, assuming nil intraoperative complications
- Proceed to OT
- Lung protective ventilation strategies given likely severe bullous disease.
- Risk of tension pneumothorax intraoperatively.