Pharyngeal Surgery: Meningitis Following Accidental Rupture of a Meningocele

Abstract

Problems and complications of cleft lip and palate cases have been well documented in the literature for many years. One would think that most of the possible complications should have been covered. This is a report 'of an unusual complicatiOn that occurred during a retropharyngeal dissection on a bilateral cleft lip and palate patient. Case Report This case involves a 13 yr. old white male (S.G.) who was born with a bilateral, complete cleft of the primary and secondary palates. The lip was repaired at four months of age and the palate at twenty-seven months. A columnellar lengthening was done at four years; a push back of the palate with nasal mucosal flaps at siX years; and a stabilization of the premaxilla with a bone graft at seven years. The patient had velopharyngeal incompetence with the characteristic nasal speech. This velopharyngeal incompetence was verified by X—ray studies that also showed cervical spine abnormalities with incomplete segmentation of the vertebrae of Ca, 03 and C.1 (Figure 1.). At 13 years of age an operation was carried out to insert an implant in the retro— pharyngeal space. During the process of the blunt dissection in the retropharyn— geal space, a moderately firm resistance was encountered over the prevertebral fascia at the C1 level. This gave way with a palpable " pop " or " snap " and spinal fluid suddenly appeared in the wound. The dissection was immediately terminated and the incision closed in a watertight manner with a two layer closure. The patient was placed on oral, antibiotics postoperatively. He became febrile within twenty hours, his temperature rising to 105.6° F., and a spinal tap showed turbid fluid from which H. influenza was isolated. He was placed on heavy doses of ampicillin and cephalosporin intravenously until sensitivity studies were com— pleted and then the cephalosporin was discontinued. He responded well to this treatment and the meningitis cleared within ten'days without sequelae. Radiographs After the meningitis cleared, basilar skull and spinal column radi— ographic studies showed abnormalities of the basilar skull and cervical spine. The cervical spine films illustrated incomplete segmentation of 02, Cg and 0.; with spina bifida occulta of the posterior neural arch of C4 (Figure 1). The basilar skull films (Figure 2A and B) showed deformities of the foramen magnum, 01 and 02. The foramen magnum was greatly enlarged and deformed with a " pear—shape " due to failure of fusion of the 215