A minimally invasive approach to refractory cerebrospinal fluid rhinorrhea after frontal craniotomy and sinus cranialization

Abstract

Cerebrospinal fluid (CSF) leakage can pose a treatment dilemma for otolaryngologists. Refractory CSF rhinorrhea presents an even greater challenge for repair. Major concerns for patients with this problem include the possibility of meningitis and other intracranial complications related to persistent pathways between the sinuses and the brain. Many methods of repair exist, all with attendant morbidity. In 1926, Dandy described intracranial repair through a bifrontal craniotomy. 1 This remained the standard approach for many years. Disadvantages of this approach included the disruption of the olfactory tracts and subsequent anosmia, as well as the increased morbidity associated with intracranial approaches in general. Failure rates with this approach have been reported to be as high as 27%, and despite multiple attempts at closure, persistent leaks have occurred. In 1948, Dohlman reported extracranial repair of CSF rhinorrhea via a naso-orbital incision. 2 Multiple modifications of this approach were designed, including the Lynch, Killian, and Lothrop procedures. Osteoplastic flaps with adipose obliteration of the frontal sinus were frequently used approaches to stop leaks emanating from the frontal sinus. Recently, endoscopic repairs have been used more frequently. Wigand, 3 Stankiewicz, 4 and Kennedy and Mattox 5 have described methods of this type of repair. Endoscopic repairs in general are very successful, with a 94% success rate reported in one series. 6 Free or pedicled mucosal grafts, as well as muscle and facial grafts, have been used to create an adequate tissue barrier between the sinuses and the intracranial contents.