Closure of a sinocutaneous fistula using a titanium mesh plate following surgical treatment of ethmoid haematoma

Closure of a sinocutaneous fistula using a titanium mesh plate following surgical treatment of ethmoid haematoma | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 25 November 2025 V1 Latest version Share on Closure of a sinocutaneous fistula using a titanium mesh plate following surgical treatment of ethmoid haematoma Authors : Marie Pia Paola Häußling 0009-0001-6808-586X [email protected] and Tim Steinberg Authors Info & Affiliations https://doi.org/10.22541/au.176407786.63897032/v1 159 views 66 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Progressive ethmoid haematomas (PEH) are benign but locally expansive lesions of the equine ethmoturbinates and may cause marked anatomical disruption. Computed tomography (CT) provides superior delineation of lesion extent. Surgical treatment via bone flap techniques is commonly performed for extensive PEH but is associated with notable risks, including haemorrhage and postoperative complications. Chronic sinocutaneous fistula formation is rare and particularly challenging when secondary infection is present. Objectives: To describe the diagnostic findings, surgical management and long-term outcome in a mare with bilateral PEH complicated by persistent sinocutaneous fistula formation and methicillin-resistant Staphylococcus aureus (MRSA) infection. Study design: Case report. Methods: A Warmblood mare with episodic epistaxis underwent endoscopy, radiography and CT, which confirmed bilateral PEH. An initial right-sided bone flap procedure was aborted due to severe intraoperative haemorrhage, and intralesional formalin was administered. Postoperative wound dehiscence progressed to a 3 × 1.5 cm sinocutaneous fistula. One year later, repeat CT revealed persistent PEH, an extensive maxillary bone defect and cutaneous invagination into the sinus. Revision surgery included debridement, reconstruction using a titanium mesh plate secured with cortical screws and skin closure via an advancement flap. Postoperative management involved systemic antimicrobials, cold-plasma treatment and further formalin injection. Results: Healing was prolonged due to MRSA infection, intermittent exudation and eventual loosening and exposure of the titanium mesh. Implant removal and subsequent resuturing resulted in successful wound closure. Follow-up CT and endoscopy at one year confirmed complete fistula resolution without recurrence of the PEH. Main limitations: Single case; findings may not be generalisable. Conclusions: Titanium mesh can provide effective temporary structural support for managing large osseous defects associated with sinocutaneous fistulae. Secondary MRSA infection significantly delayed healing. Emerging cold atmospheric plasma–aerosol technology may offer valuable adjunctive benefits in contaminated sinus surgery. Closure of a sinocutaneous fistula using a titanium mesh plate following surgical treatment of ethmoid haematoma Background: Progressive ethmoid haematomas (PEH) are benign but locally expansive lesions of the equine ethmoturbinates and may cause marked anatomical disruption. Computed tomography (CT) provides superior delineation of lesion extent. Surgical treatment via bone flap techniques is commonly performed for extensive PEH but is associated with notable risks, including haemorrhage and postoperative complications. Chronic sinocutaneous fistula formation is rare and particularly challenging when secondary infection is present. Objectives: To describe the diagnostic findings, surgical management and long-term outcome in a mare with bilateral PEH complicated by persistent sinocutaneous fistula formation and methicillin-resistant Staphylococcus aureus (MRSA) infection. Study design: Case report. Methods: A Warmblood mare with episodic epistaxis underwent endoscopy, radiography and CT, which confirmed bilateral PEH. An initial right-sided bone flap procedure was aborted due to severe intraoperative haemorrhage, and intralesional formalin was administered. Postoperative wound dehiscence progressed to a 3 × 1.5 cm sinocutaneous fistula. One year later, repeat CT revealed persistent PEH, an extensive maxillary bone defect and cutaneous invagination into the sinus. Revision surgery included debridement, reconstruction using a titanium mesh plate secured with cortical screws and skin closure via an advancement flap. Postoperative management involved systemic antimicrobials, cold-plasma treatment and further formalin injection. Results: Healing was prolonged due to MRSA infection, intermittent exudation and eventual loosening and exposure of the titanium mesh. Implant removal and subsequent resuturing resulted in successful wound closure. Follow-up CT and endoscopy at one year confirmed complete fistula resolution without recurrence of the PEH. Main limitations: Single case; findings may not be generalisable. Conclusions: Titanium mesh can provide effective temporary structural support for managing large osseous defects associated with sinocutaneous fistulae. Secondary MRSA infection significantly delayed healing. Emerging cold atmospheric plasma–aerosol technology may offer valuable adjunctive benefits in contaminated sinus surgery. Keywords: ethmoid haematoma, paranasal sinuses, fistula, bone flap, titanium mesh, trepanation, MRSA infection Introduction Progressive ethmoid haematomas (PEH) in horses are benign but locally expansive lesions that typically originate in the ethmoturbinates. Clinically, they most often manifest as recurrent, unilateral epistaxis and represent an important differential diagnosis in equine nasal bleeding [1; 2]. Despite their benign histological nature, PEH can cause significant anatomical and functional disruption due to their location and potential for expansion, including obstruction of nasal airflow, facial deformity, and damage to neighbouring structures [3]. The primary diagnostic method is usually an endoscopic examination of the nasal passage and ethmoid region. Although radiography and endoscopy are commonly applied, they often fail to fully delineate the lesion, particularly during early development [1; 4]. Advanced imaging techniques, especially computed tomography (CT), offer superior diagnostic accuracy by enabling detailed visualisation of lesion morphology, extent, and spatial relationship to adjacent osseous and soft tissue structures [1]. Distinctive imaging characteristics of PEH, such as moderate internal heterogeneity, a characteristic swirling pattern, and minimal bone destruction, assist in differentiation from other space-occupying sinus pathologies such as paranasal sinus cysts or neoplasms [1]. Therapeutic strategies for PEH include formalin injections, surgical removal and endoscopic laser ablation, depending on lesion size, localisation, and the availability of facilities [3]. Conventional surgical interventions, encompassing bone flaps and trepanation, are the prevailing treatment for lesions affecting the sinus system. These surgical procedures are performed on standing, sedated horses or under general anaesthesia. These devices facilitate the comprehensive removal of the affected tissue [5; 6]. However, such interventions are not without complications. Intraoperative haemorrhage remains a significant concern and may necessitate incomplete excision or additional medical management postoperatively [3]. Severe and protracted postoperative complications can result in the development of a persistent sinus-cutaneous fistula. These fistulae can result in chronic exudation, risk of secondary infection, delayed wound healing, and cosmetic disfigurement. Their management is particularly challenging, especially when conventional wound closure attempts fail. In select cases, the use of biocompatible materials such as titanium mesh has been explored as a method for surgical closure, with promising results in soft tissue and craniofacial applications [7; 8]. While titanium mesh implants are well-established in human medicine [9; 10], reports on their use in equine sinus surgery remain limited. This case report describes the complex diagnostic and therapeutic course of a Warmblood mare with bilateral PEH complicated by chronic sinocutaneous fistula formation following surgical intervention. Over a treatment period spanning more than two years, multiple diagnostic imaging modalities and therapeutic strategies were employed, including CT imaging, bone flap surgery, formalin application, and eventual fistula closure using titanium mesh. This report highlights the clinical challenges associated with PEH complicated by fistula formation and discusses innovative approaches that may support successful long‑term outcomes. Methods Medical history and initial presentation A warmblood mare, born in 2011, was initially presented in June 2022 due to episodic epistaxis. An endoscopic examination performed at another clinic in February 2023 revealed an enlargement in the ethmoidal region. Radiography demonstrated increased soft‑tissue opacity within the right paranasal sinuses. Subsequent CT imaging identified a soft‑tissue–dense mass occupying the right maxillary sinus caudalis, the sphenopalatine sinus, and the right ethmoid turbinates, extending into the common nasal meatus (Fig. 1), with additional extension towards the left side (Fig. 2). The differential diagnosis was bilateral ethmoid haematoma. The mare also showed clinical signs consistent with mild sinusitis. Surgical intervention In February 2023, surgical removal of the lesion was attempted using two maxillary bone flaps on the right side with the mare standing under sedation (Fig. 3). However, due to marked intraoperative haemorrhage, the procedure had to be aborted before complete removal of the lesion. The extent to which the bone flap segments were replaced and stabilised using the bone‑flap (Bonflap) technique remained uncertain. Multiple intralesional formalin injections were administered endoscopically to reduce the remaining mass. Postoperative complications Two weeks postoperatively, a wound‑healing disorder developed at the medial skin suture, accompanied by moderate exudation. An additional attempt at skin closure was made using new sutures (Figs. 4). Four weeks after surgery, persistent swelling arose near the left eye, attributed to sutureitis . Despite several attempts, skin adaptation was unsuccessful (Figs. 5). Subsequently, a sinocutaneous fistula measuring approximately 3 × 1.5 cm developed in the right maxillary bone, located rostrodorsal to the right eye. The fistula produced chronic purulent, low‑grade exudation (Fig. 6). Outpatient wound management included daily cleaning and bandaging. No further attempt at primary skin closure was made. Second presentation and renewed diagnosis In March 2024, one year after the initial intervention, the mare was referred to another clinic for re‑evaluation and attempted fistula closure. CT imaging revealed the presence of a bilateral ethmoid haematoma in the right and left sphenopalatine sinuses and in the ventral ethmoid turbinates of the right (Fig. 7a) and left ethmoid hemispheres (Fig. 7b). The haematoma protruded rostrally on the left side, extending into the left common nasal passage. Additionally, the examination revealed bone loss in the right maxillary bone (5,8 x 4,5cm) with an opening in the maxillary sinus caudalis (Fig. 8), chronic mucosal thickening in the right rostral and caudal paranasal sinuses, and soft tissue swelling at the level of the left lacrimal bone, rostral to the left eye (Fig. 9). Endoscopic evaluation confirmed prominent ethmoid haematomas on both the right and left sides (Fig. 10). The skin had invaginated into the sinus cavity, rendering secondary intention healing impossible due to the extent of the bone defect. In the course of the endoscopic evaluation, the presence of a prominent ethmoid haematoma became apparent, visible on both the right and left sides (Fig. 11). Surgical procedure Revision surgery was performed under general anaesthesia with the mare in lateral recumbency. Prior to the surgical site preparation in accordance with aseptic protocols, a swab sample of the exudate from the fistula area was collected for bacteriological culture. The skin was circumferentially dissected away from the underlying bone; it was determined that the skin had already grown deeply into the sinus cavity. Following the separation of the skin, the mesh (titanium-„mesh“-plate, 67 x 82 x 1.5 mm, medicon®) was applied directly onto the bone surface and secured in place with four self- tapping cortical screws (1mm length). The closure of the skin was achieved through the implementation of an advancement flap procedure. Skin closure was achieved using an advancement flap technique, followed by vertical mattress and simple interrupted sutures in multiple layers using 2‑0 nylon. Complete closure was not possible due to insufficient skin availability (Fig. 11). Postoperative management The surgical site was protected with a plaster dressing and a mask, changed daily. Postoperative medication included penicillin (21 mg/kg IM once daily), gentamicin (6.6 mg/kg IM once daily), metronidazole (25 mg/kg PO twice daily; due to the presence of mucous yellowish secretion with blood admixtures in the tube), flunixin meglumine (1.1 mg/kg PO twice daily), and omeprazole (1 mg/kg PO once daily) for five days. After eight days, a mild wound infection developed (Fig. 12). Bacteriological analysis performed three days after surgery revealed MRSA infection, indicating pre‑existing contamination. Daily cold‑plasma treatment (PlasmaDerm®) was initiated. Two weeks postoperatively, the ethmoid haematoma was injected with 10 ml 10% formalin. The mare was discharged three weeks after surgery. At home, wound care consisted of daily cleaning with a hypochlorous‑acid irrigation solution (Granudacyn®, Mölnlycke Health Care GmbH), followed by soft‑laser therapy to promote healing. A thin layer of Manuka honey (100% Wound Gel®, Manuka Vet) was applied to the wound margins and the site covered with a dressing. Over the following months, alternating phases of exudation occurred while new epithelial tissue gradually proliferated over the titanium mesh from the wound margins (Fig. 13-15). Following a period of six months, a minor degree of swelling was observed in the area of the surgical site. Two further areas of minor exudation were observed. Directly lateral to the original granulation site, the titanium mesh was visible (Fig. 16). Radiography and ultrasonography at a partner clinic confirmed that the titanium mesh and screws had loosened (Fig. 17). The implant was removed and the skin sutured in a single layer (Fig. 18). Formalin was again administered to the ethmoid haematoma. Two weeks later, the wound was fully closed without further exudation. Long-term course A follow-up examination in April 2025 confirmed stable and intact wound healing (Fig. 19). Subsequent endoscopy and CT imaging revealed complete closure of the defect (Fig. 20). One year after final fistula closure, no recurrence of the lesion or fistula was detected. Discussion Ethmoid haematomas present a therapeutic challenge, especially in cases of extensive or bilateral involvement. Surgical removal via bone flaps is an effective procedure, but it is also prone to complications, as demonstrated in this case by intraoperative bleeding and wound-healing disorders and suturitis. The subsequent development of a chronic sinocutaneous fistula with direct communication into the paranasal sinuses represents an uncommon but clinically significant complication. In consideration of the substantial bone defect resulting from the extraction of bone during the bone flap operation combined with movement of air pressure during respiration, complete cutaneous closure was deemed impracticable without using a stabilising structure to bridge and support the defect. The use of titanium mesh for reconstruction of osseous or soft-tissue defects is well documented in human medicine [9; 10] but rare in the veterinary medicine [7; 8]. Two case reports [11; 12] have been documented in the literature, in which sinuscutaneous fistulas were closed secondary to trauma. In both cases, a periosteal flap was utilised to effect closure of the fistula. The objective of this technique was to close the bone defect and thus achieve skin closure. In the current case, however, the application of a lattice‑structured titanium plate served to replace the missing maxillary bone and provide mechanical support for cutaneous advancement and subsequent epithelialisation. Titanium is known for its biocompatibility, low density, malleability, and mechanical stability, making it a suitable implant material for such reconstructive procedures. However, in this particular instance, the process was complicated by a secondary MRSA infection. After approximately 6.5 months, it became necessary to remove the mesh entirely because both the titanium plate and screws had loosened, most likely as a consequence of the infection. Importantly, by the time of removal, complete epithelial coverage had already been achieved, allowing the wound to remain closed thereafter. Ultimately, long‑term healing was only achieved more than two years after the initial surgical intervention. Ethmoid haematomas present a therapeutic challenge, particularly in cases of extensive or bilateral findings. Surgical removal using bone flaps remains the treatment of choice if the lesions are large and extend to the sinuses [13]; however, this approach carries a considerable risk of intraoperative and postoperative complications, as illustrated in the present case by severe bleeding and subsequent wound healing disorders. In this case, the patient exhibited pronounced suture dehiscence due to inadequate bone, which was not replaced or fixed, as is generally performed in bone flap techniques. Trepanation could theoretically have provided an alternative approach with a lower complication rate, although the significantly smaller access window limits direct visualisation and may restrict the surgeon’s ability to remove the lesion completely. For improved diagnostic accuracy and surgical planning, the establishment of a classification system for PEH based on anatomical localisation is recommended. A distinction must be made between the following forms of PEH: nasal PEH (affecting only the nasal passages), sinus PEH (affecting only the paranasal sinuses) and nasosinus PEH (affecting both the nasal passages and the paranasal sinuses). In instances where the PEH cannot be clearly defined endoscopically, it is recommended that a CT scan be performed to determine the exact location of the tissue growth and to plan a possible operation. Furthermore, it would be interesting to know why some ethmoid haematomas grow towards the nose and others towards the sinuses, or whether the exact location of origin in the ethmoid bone is responsible for this. It is evident that further research and studies are required to provide answers to these questions. Nevertheless, in the current case, secondary infection with methicillin-resistant Staphylococcus aureus (MRSA) complicated the postoperative course, ultimately necessitating implant removal and resulting in delayed healing. In order to reduce the MRSA bacteria, a cold plasma device from PlasmaDerm®, which relies on direct tissue contact, was used postoperatively, the treatment intensity appears to have been insufficient to eradicate the infection. Recent research into Cold Atmospheric Plasma-Aerosol (CAP-A) technology suggests a promising adjunctive strategy for infection control and wound conditioning in surgical patients. CAP-A represents an indirect, contact-free plasma approach in which reactive oxygen and nitrogen species via a water-vapour-based plasma are delivered via an aerosol phase. This mechanism allows efficient antimicrobial action without direct energy transfer to the treated surface, thereby avoiding thermal or oxidative tissue damage [14]. If a CAP-A device had been available and used preoperatively in the present case (maybe also as an inhalation), perioperative microbial reduction and improved tissue conditioning might have mitigated or even prevented the wound healing disorder. Integrating plasma-based antimicrobial technology into standard surgical protocols, particularly for procedures involving implant materials, could therefore represent a valuable preventive measure. Conclusion This case report demonstrates the complexity of managing bilateral ethmoid haematomas complicated by secondary sinocutaneous fistula formation following bone flap surgery. Successful long-term resolution required a combined surgical and conservative therapeutic approach, underpinned by intensive postoperative monitoring. The application of titanium mesh as a temporary structural scaffold proved effective in facilitating stable soft‑tissue coverage and enabling eventual fistula closure, even though the implant had to be removed due to secondary MRSA-associated loosening. This case highlights that titanium mesh may represent a viable reconstructive option for large osseous defects associated with fistula formation in equine patients. Furthermore, the protracted course of healing underscores the importance of rigorous infection control measures, particularly in the presence of resistant organisms such as MRSA. Adjunctive technologies, including emerging Cold Atmospheric Plasma–Aerosol (CAP-A) systems, may provide valuable preventative or therapeutic support in similar cases by reducing microbial load and improving tissue healing capacity. Overall, this report illustrates the need for individualised, multimodal treatment strategies in complex sinus pathologies and emphasises the potential benefit of integrating innovative reconstructive and antimicrobial approaches to optimise long‑term outcomes. [1] Berner, D., Hellige, M., Harvey, G.G., Gerlach, K., Iglesias-Garcia, M. and Manso-Diaz, G. (2025) Differentiation of equine paranasal sinus cysts and progressive ethmoid haematomas on computed tomographic images. J Equine Vet Sci 150 , 105609.[2] Fey, K. and Ohnesorge, B. (2017) Krankheiten der Atmungsorgane. In: Handbuch Pferdepraxis Eds: O. Dietz and B. Huskamp, Enke, Stuttgart. pp 332-334.[3] Frees, K.E., M., G.E., D., L.J., J., C., D., G., Nietfeld, N.J.C., A., K.G. and W., C. (2001) Severe complication after administration of formalin for treatment of progressive ethmoidal hematoma in a horse. JAVMA 219 , 950-952.[4] Dixon, P.M., Kennedy, R., Poll, K., Barakzai, S. and Reardon, R.J.M. (2021) A long-term study of sinoscopic treatment of equine paranasal sinus disease: 155 cases (2012-2019). Equine Vet J 53 , 979-989.[5] Schumacher, J., Dutton, D.M., Murphy, D.J., Hague, B.A. and Taylor, T.S. (2000) Paranasal sinus surgery through a frontonasal flap in sedated, standing horses. Vet Surg 29 , 173-177.[6] Robert, M.P., Stemmet, G.P. and Smit, Y. (2019) A bilateral sinus cyst treated via a bilateral frontonasal bone flap in a standing horse. J S Afr Vet Assoc 90 , e1-e6.[7] Graham, S.B., Schilpp, D., Bradley, W.M., Cook, G. and Gayle, J. (2010) Treatment of traumatic tracheal collapse with extraluminal titanium mesh screens. Equine Veterinary Education 22 , 557-563.[8] Mählmann, K. and Lischer, C.J. (2025) Resorbable plates and space for innovative approaches: Equine facial fracture repair. Equine Veterinary Education 37 , 410-415.[9] Soares, K.H., King, C., Palkovics, D., Perez, R., Mbadu, M., Duarte, W.R., Schey, K.C. and Duarte, P.M. (2025) Customized three-dimensional-printed titanium mesh for alveolar bone augmentation: Retrospective consecutive case series. Clin Adv Periodontics .[10] Paiva, C., Tavares, R.N., Chaves, F.N. and Carvalho, F.S. (2025) Rapid and Low-Cost Mesh Shaping Technique for Orbital Fracture Reconstruction - A Technical Note. J Oral Maxillofac Surg 83 , 1266-1270.[11] Velde, K., Linsbichler, B., Egerbacher, M. and Stashak, T. (2011) Use of reversed periosteal flaps in the repair of large nasocutaneous fistulas in two horses. Equine Veterinary Education 23 , 235-241.[12] Charman, R.E. and Vasey, J.R. (2007) Repair of sinocutaneous fistulae in two horses. Aust Vet J 85 , 341-344.[13] Auer, J.A. and Stick, J.A. (2018) Equine Surgery .[14] Schaal, T., Schmelz, U., Hammerle, G., Fuchs, R., Schorling, T., Kurras, S., Koene, M. and Tischendorf, T. (2025) Analysis of antimicrobial effects of a contactless, indirect cold atmospheric plasma-aerosol method for germ reduction on surfaces: an in vitro and in vivo study. Front Microbiol 16 , 1668987. Supplementary Material File (figures.docx) Download 82.38 MB File (image1.emf) Download 12.47 KB Information & Authors Information Version history V1 Version 1 25 November 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Marie Pia Paola Häußling 0009-0001-6808-586X [email protected] Tierklinik Lusche GmbH View all articles by this author Tim Steinberg Tierklinik Lusche GmbH View all articles by this author Metrics & Citations Metrics Article Usage 159 views 66 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Marie Pia Paola Häußling, Tim Steinberg. Closure of a sinocutaneous fistula using a titanium mesh plate following surgical treatment of ethmoid haematoma. Authorea . 25 November 2025. DOI: https://doi.org/10.22541/au.176407786.63897032/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.176407786.63897032/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fffca12b87e0db4',t:'MTc3OTQ5NDUyMA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();