Endoscopic Endonasal Repair Research Articles

Modified graded skull base reconstruction for intraoperative CSF leak repair in endoscopic endonasal surgeries: a single-surgeon experience in initial years of practice and nuances in the early learning curve.

The purpose of this study was to evaluate the outcome of a modified graded reconstruction technique based on the size of intraoperative CSF leaks in patients undergoing endoscopic endonasal surgery performed by a single surgeon in the early years of his practice. The database of patients who underwent endoscopic endonasal approaches (EEAs) between September 2020 and August 2024 was included. Surgical complexity was categorized into levels II, III, and IV. Intraoperative CSF leak was categorized into 4 grades (0-3). Patients were divided into 2 timeline groups (those undergoing an EEA between 2020 and 2022 [group A] and between 2023 and 2024 [group B]) to assess the trends in surgical complexity and repair outcomes. A total of 69 patients with a mean age of 56 ± 16.9 years (range 12-83 years) were identified; 34 (49.3%) were female. The median body mass index was 31 (> 25 in 82.6%). The most common pathology was nonsecretory macroadenoma (57.9%). The EEA at complexity levels II, III, and IV was performed in 36.2%, 46.4%, and 17.4% of the patients, respectively. Intraoperative CSF leaks grades 1, 2, and 3 were encountered in 39.1%, 7.2%, and 17.4% of the patients, whereas 36.2% did not develop leaks (grade 0). Fat grafts and collagen matrix were used for all patients with grades 1-3. Patients with complexity level II only developed grade 1 and 2 leaks, and none of level III developed grade 3. A nasoseptal flap was used in 4 patients (5.8%), with all having level IV surgery and grade 3 intraoperative leak. Only 1 patient (1.4%) developed a postoperative CSF leak, and a lumbar drain was only used for this patient (1.4%) at the revision surgery. The rate of grades 2 and 3 leaks in group B was significantly lower than in group A (8.3% vs 33.3%, p = 0.022). Temporary nasal packing usage was also significantly lower in group B (8.3%) than in group A (28.9%) (p = 0.049), whereas high-complexity EEA rates and pedicled flap usage were not correlated with the year of surgery. A graded endoscopic endonasal repair protocol, combined with the judicious use of lumbar drains and nasoseptal flaps rather than a reflexive approach, helps in minimizing postoperative CSF leak rates. Cross-training of neurosurgery graduates focusing on skull base practice is highly recommended for maximizing good outcomes in their early years of practice. With growing experience, intraoperative leak rates tend to decrease, and the reconstruction relies on a tailored multilayer strategy rather than bulky synthetic materials.

What is the risk of meningitis, utilising a single agent, single dose perioperative antibiotic following endonasal endoscopic repair of a CSF leak?

What is the risk of meningitis, utilising a single agent, single dose perioperative antibiotic following endonasal endoscopic repair of a CSF leak?

Endoscopic Endonasal Anterior Skull Base Meningoencephalocele and Cerebrospinal Fluid Leak Repair: Our Intraoperative and Postoperative Protocol and Long-term Outcomes

Abstract Objective We evaluated the long-term outcomes from a single neurosurgeon and otolaryngologist team using a specific operative protocol for repair and postoperative evaluation. Design The charts of patients undergoing endoscopic endonasal repair of meningoencephaloceles (MECs) and cerebrospinal fluid (CSF) leaks were retrospectively reviewed from 2015 to 2023. Intraoperative steps of the repair and reconstruction were analyzed. Patients' postoperative assessments and complications were analyzed. Setting Loyola University Medical Center's electronic medical record database. Participants Forty-three patients (32 female) aged between 11 and 81 years. Main Outcome Measures Long-term outcomes of patients who underwent endoscopic endonasal repair of MECs and CSF leaks by a single team and protocol. We hypothesized that there would be minimal complications and no recurrences, requiring secondary operation. Results The most common site for MECs was the cribriform plate. Lumbar drain opening pressures ranged from 10 to 35 cm H2O with 18 out of 34 patients having the lumbar drain removed immediately postoperatively. The median hospital stay was 3 days. The average length of follow-up was 3.8 years. No recurrences or secondary operations were noted in all patients. One patient had a sinonasal infection that was successfully treated. Eight patients were noted to have venous stenosis and underwent further evaluation. Conclusion This study represents one of the largest long-term analyses of outcomes by a single team. Our specific protocol for the endoscopic endonasal repair of anterior skull base MECs and CSF leaks is safe and effective. These patients should be evaluated and treated for elevated intracranial pressure following the repair.

Endoscopic endonasal repair of temporal lobe meningoencephalocele in the lateral recess of the sphenoid sinus, complicated by intracerebral hematoma: illustrative case.

Anomalies in the anatomical structure of the nasal cavity and paranasal sinuses often serve as a potential cause of spontaneous cerebrospinal fluid (CSF) leakage and may result in the development of a meningoencephalocele. In this report, the authors present a case of surgically treated intrasphenoidal meningoencephalocele attributed to the persistence of the lateral craniopharyngeal canal, which was further complicated by the occurrence of an intracerebral hematoma. A temporal lobe meningoencephalocele located in the lateral recess of the sphenoid sinus was successfully managed using endoscopic endonasal transpterygoid repair (EETR). However, an intracerebral hematoma developed after resection of the meningoencephalocele, necessitating additional surgical interventions. Despite this complication, the patient exhibited a favorable clinical outcome after the surgical interventions. This case highlights the potential risk of intracerebral hematoma associated with EETR of a lateral sphenoid sinus meningoencephalocele. A thorough examination of magnetic resonance imaging scans, especially identifying vascular structures, is crucial during surgical planning. This knowledge can help to prevent the occurrence of complications, including intracerebral hematoma.

Delayed diagnosis and management of a congenital intranasal meningoencephalocele in a 24-year-old male

Background: Intranasal meningoencephalocele is a rare congenital malformation. It is defined by protrusion of cerebral tissue and meninges through a defect in the skull base. Serious complications usually occur in early childhood, however, symptoms occasionally can wait until adulthood. Case Presentation: We report a case of a 24-year-old male who had a congenital intranasal meningoencephalocele with recurrent episodes of bacterial meningitis. After a delayed diagnosis, he eventually underwent Endoscopic Endonasal Repair of Meningoencephalocele via 'Bath-plug' technique. Conclusions: To prevent improper management, it is crucial that ENT colleagues, to whom these cases are primarily present, are well informed about this unusual condition. For the purpose of preventing further neurological problems, thorough neuroimaging evaluations and successful surgical repair are important. The 'Bath-plug' technique for anterior skull base cerebrospinal fluid leak repair is effective for a wide range of situations.

The Etiology, Diagnosis, and Management of Cerebrospinal Fluid Rhinorrhea: A Tertiary Center Experience.

Introduction The aim of the present study was to describe our institution's nine years of experience in the endoscopic endonasal management of cerebrospinal fluid (CSF) rhinorrhea and to discuss the causes, sites, and outcomes. Methodology The medical records of patients diagnosed with CSF rhinorrhea in King Abdulaziz Medical City-Jeddah (KAMC-J) between 2014 and 2023 were retrospectively reviewed, and all relevant information including body mass index, medical and surgical history, and postoperative outcomes were obtained. Results A total of 20 cases were included in the present study, sixteen (80%) of which were females and four (20%) were males. The mean age of participants was 42.59±13.9 years. Nine cases (45%) were spontaneous CSF rhinorrhea and 11 (55%) were traumatic; within the traumatic group, six cases (54%) were iatrogenic either following previous neurosurgery or functional endoscopic sinus surgery, while the remaining five cases were related to motor vehicle accidents. The mean body mass index for the spontaneous CSF leak was 32 Kg/m2, and 33 Kg/m2 for the traumatic leaks, no statistically significant difference was noted. The cribriform plate was the most common site of leakage (65%). A multilayer surgical technique using facia lata graft with nasoseptal flap was the most common choice for reconstruction with a first-attempt success rate approximating 90%. A recurrence was observed in two patients only. No major complications were reported. The average length of stay was nine days. Conclusion The endoscopic endonasal repair of CSF leak is a safe and reliable procedure and is associated with high success rates and low risk of complications. Therefore, it should be preferred as a first-line treatment for CSF rhinorrhea.

Management of Traumatic and Non-Traumatic Cerebrospinal Fluid Rhinorrhea-Experience from Three Southeast Asian Countries.

Cerebrospinal fluid (CSF) rhinorrhea requires proper management to avoid disastrous consequences. The objectives of this study were to ascertain the patient characteristics, etiologies, sites of defect, skull base configurations, methods of investigation, and management outcomes of CSF rhinorrhea. A retrospective study was performed over 4 years involving three surgeons from Malaysia, Singapore, and Thailand. Hospital records were reviewed to determine the patients' characteristics, the causes and sites of leaks, methods of investigation, skull base configurations, choices of treatment, and outcomes. A total of 15 cases (7 traumatic and 8 non-traumatic) were included. Imaging was performed in all cases. The most common site of leakage was the cribriform plate (9/15 cases). The mean ± SD of the Keros heights were 4.43 ± 1.66 (right) and 4.21 ± 1.76 mm (left). Type II Keros was the most common (60%). The mean ± SD angles of the cribriform plate slope were 51.91 ± 13.43 degrees (right) and 63.54 ± 12.64 degrees (left). A class II Gera configuration was the most common (80%). All except two patients were treated with endonasal endoscopic surgical repair, with a success rate of 92.3%. A multilayered repair technique was used in all patients except one. The mean ± SD postoperative hospital stay was 9.07 ± 6.17 days. Non-traumatic CSF rhinorrhea outnumbered traumatic CSF rhinorrhea, with the most common site of leak at the cribriform plate. Imaging plays an important role in investigation, and Gera classification appears to be better than Keros classification for evaluating risk. Both conservative and surgical repairs are practiced with successful outcomes. Endonasal endoscopic CSF leak repair is the mainstay treatment.

Endoscopic Endonasal Repair of Congenital Choanal Atresia: Predictive Factors of Surgical Stability and Healing Outcomes.

Background: To assess the long-term outcomes and independent predictors of surgical success of a one-stage minimally invasive surgical procedure for congenital choanal atresia (C.C.A.). Methods: a retrospective multicentric study was conducted between 2010 and 2022. An endonasal endoscopic approach was performed in 38 unilateral or bilateral C.C.A. children. All the patients were clinically and radiologically assessed and followed for at least 2 years. Seven outcome measures were applied. Consequently, surgical success was correlated with all the independent variables reported. Results: 18/38 (47.36%) patients presented normal postoperative healing, 8/38 (21.05) had moderate restenosis (<50%), while 12/38 (31.57%) cases were severe (>50%), requiring a surgical revision. No statistical significance was found for average hospital stay between stenosis >50% and <50% patients (p = 0.802) and postoperative pain (p = 0.075); instead, the severe restenosis group demonstrated a higher delay of breast suction (p < 0.001). Among the independent variables predictors of surgical success, the presence of Charge syndrome and rhinopharyngeal stenosis demonstrated higher risks for surgical revision (OR: 4.00, 95% CI: 0.57–28.01, and OR: 2.75, 95% CI: 0.55–13.69, respectively). On the contrary, the hypoplastic inferior turbinate and bilateral C.C.A. showed a lower risk for severe restenosis by a higher endoscopic surgical space and creating a single larger opening (OR: 0.88, 95% CI: 0.22–3.52, and OR: 0.45, 95% CI: 0.10–2.08). Conclusion: Several independent variables could influence the surgical success after C.C.A. endoscopic repair; however, more high-quality evidence is needed to generate an effective predictive model.

The critical importance of a vascularized flap in preventing recurrence after endoscopic repair of spontaneous cerebrospinal fluid leaks and meningoencephaloceles.

Spontaneous CSF leaks into the anterior skull base nasal sinuses are often associated with meningoencephaloceles and occur in patients with idiopathic intracranial hypertension (IIH). Endonasal endoscopic repair has become the primary method of choice for repair. The authors sought to evaluate the success rate of endoscopic closure and to identify predictive factors for CSF leak recurrence. A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele. From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9-38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher's exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred. Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.

A Comparative Analysis of Transcranial and Endoscopic Repair for Traumatic CSF Rhinorrhea.

Surgical treatment of anterior cranial base traumatic cerebrospinal fluid (CSF) rhinorrhea is challenging and is fraught with complications. Whether a person should be offered open craniotomy or endoscopic endonasal repair is a dilemma faced by most surgeons. This study is one of the few to directly compare the two forms of management. Data were collected from two groups of 15 patients each who underwent transcranial CSF leak repair and endoscopic endonasal CSF leak repair in a tertiary care hospital over a 3-year period. Information including demographics, recurrence rates, complications, and hospital and intensive care unit (ICU) stay was recorded and analyzed. Outcome was assessed up to 6 months. Recurrence was seen in 9/30 patients, 6 in the transcranial group and 3 in the endoscopic group. Hospital stay was longer than 1 week in all the transcranially operated patients and only in 73% of the endoscopically operated patients (p = 0.439) although ICU stay was reduced in the endoscopic group (p = 0.066). Complications were more common with transcranial repair (seven of eight patients who underwent transcranial repair, p = 0.035) with anosmia being the most common (33.3%, p = 0.042). The transcranial open repair is a reasonable choice especially for leaks that occur through the frontal sinus and extend backward into the frontoethmoidal region. However, this approach has the drawbacks of greater number of complications, higher recurrence rate, and longer ICU and overall hospital stay. The endoscopic endonasal repair enjoys a lower morbidity profile although it may not be an adequate treatment for leaks that are placed far laterally in the frontal sinus.

Endoscopic Endonasal Repair of the Orbital Medial Wall Fracture Utilising Nasal Septal Cartilage as the Reconstructive Material.

To repair orbital medial wall fractures, otorhinolaryngologists often use the silicone sheet technique by inserting an inverted U-shaped silicone sheet into the middle meatus after the removal of fractured bones, and packing gauze inside the silicone sheet for several days to fix the shape of the medial wall. However, this method does not sufficiently reduce the orbital content. To describe the surgical procedure to repair medial wall fractures using nasal septal cartilage as the reconstructive material. First, endoscopic septoplasty is performed. Although the correction of the septal deviation is performed to secure the operative field, the nasal septal cartilage, except the L-strut is resected simultaneously. After septoplasty, the fractured bones of the lamina papyracea are removed from the herniated orbital contents, and then the orbital contents can be reduced without resistance by pushing laterally. Subsequently, the cartilage is inserted beneath the fracture edges of the orbital medial wall with great care to avoid entrapping the orbital soft tissue and extraocular muscles. The cartilage can be placed appropriately along the medial wall of the orbit. This technique enables to repair most cases of orbital medial wall fractures using the endoscopic endonasal approach alone without alloplastic implants.

Combined Pipeline Embolization Device with Endoscopic Endonasal Fascia Lata/Muscle Graft Repair as a Salvage Technique for Treatment of Iatrogenic Carotid Artery Pseudoaneurysm.

The incidence of internal carotid artery (ICA) injury associated with endoscopic endonasal approaches to the pituitary is less than 1%. While parent vessel sacrifice has historically been the choice of treatment, vessel-preserving endovascular techniques have been reported. Although flow diversion offers endoluminal reconstruction, its major limitation is the delay in obtaining complete occlusion. We describe the use of a combined Pipeline embolization device (PED) with endoscopic endonasal repair using a fascia lata/muscle graft to treat an iatrogenic ICA pseudoaneurysm and report long-term radiographic follow-up. Further investigation into the utility of directed endoscopic endonasal repair of iatrogenic pseudoaneurysms initially treated with PED is necessary, especially given the need of post-PED anticoagulation and the rate of permanent neurological deficit after ICA sacrifice.

Endoscopic endonasal management of skull base defects in pediatric patients

PurposeSkull base defects in children may be the result of congenital anomalies or trauma. They often present as cerebrospinal fluid (CSF) rhinorrhea, meningitis, brain abscess or nasal obstruction. Surgical intervention is predominantly the treatment of choice. Our goal is to assess the efficacy of endoscopic endonasal approach in treating skull base defects in pediatric patients. Material and methodsIn this retrospective study we identified 38 patients (mean age 8.7 ± 5.6 years old, ranging 2 months-18 years) who underwent endoscopic endonasal repair of skull base defects, between March 2010 and February 2020. Patients who had skull base reconstruction after tumor resection, those who were lost to follow-up or did not sign the consent forms were excluded from the study. ResultsThe clinical indications for endoscopic endonasal repair were trauma (n = 24, 63.1%) and congenital defects (n = 14, 36.9%). Congenital skull base defects included basal meningoencephalocele (n = 5, 35.7%) and frontoethmoidal defects (n = 9, 64.3%). Mean follow up time was 32 ± 29.04 months, ranging 2–103 months. Fat graft (alone or in combination) was the most commonly used material to repair the skull base defects. Thirty-seven patients (97%) showed successful results after endoscopic endonasal surgery and were symptom free. ConclusionThe endoscopic endonasal repair of CSF leak and skull base defects proved to be safe and feasible with 97% success rate.

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks.

Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Endoscopic endonasal repair of a temporal lobe meningoencephalocele in the pterygoid fossa: A case report and literature review

IntroductionMeningoceles are defined as herniation of the meninges through a skull base defect. If brain tissue is herniated as well, then it is called meningoencephalocele. The most common locations of meningoceles are the cribriform plate and the lateral recess of the sphenoid sinus, with the most common presentation being CSF leakage. We present a case of temporal lobe meningocele that herniated through a defect in the greater wing of the sphenoid bone to the pterygoid fossa and that was diagnosed incidentally while evaluating the patient for seizures.MethodologyCase report and literature review.ConclusionThe endonasal endoscopic approach is a suitable minimally invasive approach for the management of pterygoid fossa lesions, including meningoceles. In this case, the patient had epilepsy with the surgery resulting in the resolution of the seizures.

404 Endonasal Endoscopic Management of Spontaneous Cerebrospinal Fluid Rhinorrhoea: Birmingham Experience

Abstract Spontaneous cerebrospinal fluid (CSF) leak (SCSFL) occurs in the absence of any trauma, surgery or underlying intracranial pathology. SCSFL can lead to complications such as brain abscess, meningitis, decreased intracranial pressure (ICP), headache and brain herniation. We present our experience of SCSFL repair performed by a single surgeon at a tertiary centre via the endonasal endoscopic approach. All patients who underwent CSF fistula repair at the Queen Elizabeth Hospital Birmingham, between 1st January 2012 and 31st December 2019, were identified and had their case notes analysed retrospectively. We identified 33 patients who satisfied our inclusion criteria. They consisted of 27 (81.8%) female patients, ranging in age from 31 to 81 years (mean age 55.2 ± 13.2 years). Combined CT/MRI imaging was able to identify the leak in 30 patients (91%). Post-operative complications occurred in 2 patients (6.1%) with 1 patient developing meningitis (3.0%) and 1 patient experiencing epistaxis (3.0%). Overall, there was a successful primary repair in 32 (97.0%) cases. Endoscopic endonasal repair of SCSFL has rapidly grown in popularity and now become the treatment of choice, overtaking open transcranial approaches. Several studies have demonstrated success rates of between 80-94% for spontaneous leaks however not all have addressed the issue of concurrent IIH post-operatively.

Recurrent spontaneous CSF rhinorrhea: combined endo-nasal endoscopic repair with lumbo-peritoneal shunt insertion

BackgroundSpontaneous cerebrospinal fluid (CSF) leaks are associated with high morbidity and recurrence rates. Most cases had increased intracranial pressure (ICP) on presentation. There is still controversy regarding the use of lumbo-peritoneal shunt to prevent its recurrence.AimThis study was conducted to evaluate the impact of lumbo-peritoneal CSF shunt following the initial as well as recurrent repair of spontaneous CSF leaks to avoid recurrence.MethodsA retrospective cohort study reviewed patients with recurrent spontaneous CSF leaks over a 4-year period. All patients had increased ICP and were subjected to endoscopic repair and lumbo-peritoneal shunt procedure.ResultsEighteen patients were included in this study. Most patients were obese (BMI = 33.6 ± 1.8 kg/m2) women (88.9%), with sleep apnea syndrome (77.8%). All patients presented with headache and visual complaints. Meningitis was recorded in two patients (11.1%). The most common sites of leakage were the cribriform (66.7%), followed by both cribriform and ethmoidal (16.7%), sphenoid (11.1%), and ethmoidal (5.6%) bones. The mean defect size was 5.1 ± 1.1 mm. About one third of cases had multiple defects. Encephalocele and meningocele were encountered in 61.1% and 66.7% of cases, respectively. The mean preoperative CSF pressure was 36.5 ± 1.7 mm H2O. Lumbo-peritoneal shunt was inserted for all our patients. The failure rate of repair was 11.1%.ConclusionSuccess rate is higher in patients with spontaneous CSF leaks and CSF hypertension treated by lumbo-peritoneal shunt. Future prospective studies with larger sample sizes should confirm the efficacy and safety of this management plan.

Endoscopic endonasal repair of complete bilateral choanal atresia in neonates.

Reported success rates of endoscopic choanal atresia (CA) surgery vary substantially due to a high heterogeneity in and between study groups. Comprehensive data on the unique patient cohort of newborns with bilateral CA are scarce. Our study aimed to close this gap by using narrow inclusion criteria and standardized surgical outcome parameters. A total of ten neonates who were diagnosed with bilateral complete CA and underwent endoscopic surgery at the Department of Otolaryngology, Head and Neck Surgery in the University Hospital of Munich between 2008 and 2017 were included. Preoperative findings, surgical procedures, outcome, and follow-up were analyzed. Standardized criteria were used to assess surgical outcome. Almost all patients (90%) required at least one revision procedure within the first 6 months after initial surgery because of symptomatic partial or complete restenosis. After that, all surviving patients remained asymptomatic until the end of the follow-up period.Conclusion: Endoscopic bilateral CA repair in neonates is a safe procedure with a high long-term success rate. However, compared to other patient groups with choanal obstruction, restenosis occurs frequently, and revision procedures are required in a large number of cases. This should be considered during preoperative planning and parent counseling. What is Known: • Bilateral complete choanal atresia (CA) is a neonatal emergency that requires surgical intervention. • Reported success rates of endoscopic choanal obstruction repair are highly variable and mostly derived from heterogenous study groups that do not reflect the situation in neonates adequately. What is New: • This study focuses exclusively on newborns with complete bilateral CA who underwent endoscopic surgery within the first 28 days of life and uses standardized criteria to assess outcome. • The long-term success rate of endoscopic bilateral CA repair in neonates is high; however, almost all patients require at least one revision procedure within the first 6 months.

Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base.

Spontaneous cerebrospinal fluid (CSF) leaks of the skull base are associated with obesity, multiparity, and elevated intracranial pressure. Although spontaneous CSF leaks often present with rhinorrhea, they can be an underdiagnosed cause of chronic aspiration pneumonitis, a complication that has not been previously reported in detail. Retrospective case series. The authors retrospectively reviewed all patients undergoing surgical repair of CSF fistulae at the University of Southern California between 2011 and 2018 to identify those presenting with pulmonary symptoms including dyspnea, aspiration, chronic cough, and shortness of breath caused by chronic noniatrogenic CSF pneumonitis. Symptomatic chronic pneumonitis was evident in six of 20 patients with spontaneous CSF rhinorrhea. Five women (mean body mass index = 36) had CSF leaks arising from the fovea ethmoidalis (n = 4) and lateral sphenoid region (n = 1). One man had a middle fossa floor dehiscence draining through the eustachian tube. All patients had bilateral ground-glass opacities in their lungs on computed tomography imaging that were attributed to spontaneous CSF fistulae arising from noniatrogenic skull base defects, and one patient underwent a biopsy of a lung lesion at another hospital showing chronic bronchiolitis and adjacent peribronchiolar metaplasia. Five patients underwent endoscopic endonasal repair using an autologous fascial graft and pedicled nasoseptal flap, and one underwent craniotomy for repair. All patients underwent successful repair with no complications or evidence of recurrence. Upon repair of the spontaneous CSF leaks, both pneumonitis symptoms and ground-glass opacities on imaging resolved in all six cases. Skull base CSF fistulae should be considered as a reversible cause of chronic pneumonitis that is not alleviated or worsens with standard treatment. 4 Laryngoscope, 131:462-466, 2021.

Endoscopic Repair of Spontaneous CSF Rhinorrhoea: Results from 21 Cases

Introduction&#x0D; Surgery to close the skull base defect is the treatment of choice in persistent spontaneous cerebrospinal fluid rhinorrhoea with endoscopic endonasal repair being the method of choice. This study analysed the demographics of presentation, optimal diagnostic and localisation strategies and the effectiveness of transnasal endoscopic treatment strategies with post-operative follow-up of CSF rhinorrhoea patients in a tertiary care institution .&#x0D; Materials and Methods&#x0D; A prospective longitudinal study was conducted on 21 CSF rhinorrhoea patients operated on between August 2014 and August 2018 and results documented.&#x0D; Results&#x0D; CSF rhinorrhoea was found most commonly in middle aged female patients in our study. HRCT PNS was capable of identifying a leak site in 66% of the cases. All patients were operated endoscopically with no major intra-operative or post-operative complications. Resolution of CSF leak occurred in 85% of cases.&#x0D; Conclusion&#x0D; CSF rhinorrhoea can be diagnosed and endoscopic repair can be effectively performed in our existing tertiary care set-ups with good results.