Endoscopic endonasal multilayer repair of traumatic ethmoidal roof cerebrospinal fluid rhinorrhea in children

Abstract

ObjectivePediatric traumatic cerebrospinal fluid (CSF) leak is a challenging problem in diagnosis and management. Posttraumatic leaks frequently present by intermittent rhinorrhea or by recurrent attacks of meningitis, which can be the only presenting symptom. The objective of this study is to present our experience in management of pediatric traumatic ethmoidal roof CSF leaks using a multilayer repair technique via an endoscopic approach. MethodsTen pediatric patients (aged 4–14 years, six males and four females) presenting with posttraumatic ethmoidal roof CSF rhinorrhea were operated upon between January 2007 and December 2010, using an endoscopic endonasal multilayer repair technique. Preoperative radiological evaluation included both multidetector computed tomography (MDCT) with ultra-thin 1mm cuts, and magnetic resonance imaging (MRI) high resolution coronal T2-weighted sequence. Intraoperatively, the GE InstaTrak™ 3500 electromagnetic navigation system was used in all cases. Postoperative follow-up was done clinically by regular endoscopic examinations and radiologically by MRI assessment using the same preoperative protocol. ResultsClinically all patients presented with unilateral intermittent watery rhinorrhea with periods ranging from 5 to 24 months before operation. Seven cases had a history of recurrent meningitis. Defects were confined to ethmoidal roof in all 10 cases (right side in seven and left side in three), and ranged in size from 2 to 7mm2 (mean 3.9±1.5mm2). Two cases had more than one defect on the same side. All defects were identified preoperatively using our radiological protocol. One case was associated with a meningocele with no brain herniation and another case was associated with a small meningoencephalocele. Mean postoperative hospitalization was 6 days (range 4–8 days). None of our patients developed any intra or postoperative complications or required revision surgery with a 100% success rate after a mean follow-up duration of 29.4±14.4 months (range 12–52 months). ConclusionsPediatric posttraumatic CSF leaks involving the ethmoidal roof can be successfully managed via the endonasal endoscopic route using a multilayer repair technique, thus limiting complications associated with external approaches. Preoperative imaging including MDCT and high resolution MRI is of paramount importance for detecting the defect site and for planning surgery.