Nasal Liquorrhea Research Articles

The use of platelet gel for repair of a cerebrospinal fluid fistula of the skull base (a case report and literature review)

Nasal liquorrhea is a serious problem in surgery of skull base tumors, which is associated with a high risk of purulent-septic complications. This paper presents a case of successful repair of a cerebrospinal fluid fistula with an autologous platelet gel in the postoperative period after removal of meningioma of the anterior cranial fossa base, which was accompanied by a purulent-inflammatory complication in the surgical wound area.

Complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas

The use of endoscopic technique has significantly extended the indications for surgery using the transsphenoidal approach. Currently, more than 90% of pituitary adenomas are operated on transsphenoidally. Transnasal removal of giant pituitary adenomas has become possible. Transition to the endoscopic endonasal approach in removal of pituitary adenomas changed the rate and structure of postoperative complications. We analyzed potential complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas. These include complications of the approach itself (nasal bleeding, perforation of the nasal septum, impaired olfactory function, atrophic rhinitis, synechiae, mucoperiosteal flap necrosis, and external nasal deformities), infectious complications (meningitis, intracranial abscesses), cerebral circulation disorder (subarachnoid hemorrhage, cerebral vasospasm, injury to large vessels, intracranial hematomas), neuro-ophthalmological complications (visual and oculomotor disorders), endocrine (hypopituitarism, diabetes insipidus, hyponatremia) and somatic complications, and nasal liquorrhea. In conclusion, it should be noted that despite continuous improvement of the technique for endoscopic endonasal removal of pituitary adenomas, there is a risk of serious complications, which necessitates the development of techniques for prevention of these complications.

A supraorbital trans-eyebrow approach in surgery of chiasmatic-sellar and anterior cranial fossa tumors

to analyze 31 resections of chiasmatic-sellar region (CSR) and anterior cranial fossa (ACF) tumors using the supraorbital trans-eyebrow approach (STA). We analyzed medical histories of 31 patients who underwent tumor resection using STA in the period between October 2013 and April 2017. We analyzed the age and gender of patients, size and location of the tumor, presence of a neurological deficit, vision and olfactory functions before and after surgery, surgery duration, amount of intraoperative blood loss, rate of frontal sinus trephination and nasal liquorrhea, hemorrhagic and ischemic complications after surgery, Simpson grade of tumor resection, patient's condition before and after surgery (Glasgow Outcome Scale and Karnofsky Scale), and degree of patient satisfaction with the cosmetic result of surgery. A total of 26 meningiomas (20 sphenoid plate, tubercle, and diaphragm tumors, 3 lesser sphenoid wing meningiomas, 2 orbital roof tumors, and 1 anterior clinoid process meningioma), 3 frontal lobe gliomas, and 2 pituitary adenomas were resected. In all 31 operations, the approach was adequate and enabled tumor resection without lethal outcomes. The mean surgery duration was 174.6±64.4 min. The mean blood loss was 190±96.6 mL (50-380 mL). After surgery, none of the patients developed motor deficits and new epileptic seizures. Neurological deficit aggravation in the form of impaired vision and mental disorders occurred in 8 (25.8%) patients. Vision impaired in 4 (12.9%) patients, improved in 6 (19.3%) patients, and remained unchanged in 21 (67.7%) patients. An endocrinological deficit in the form of partial hypopituitarism developed in 3 (9.6%) patients; in 4 (12.9%) patients, there were mental disorders that regressed by the end of the first month of therapy. There were no intracerebral and subarachnoid hemorrhages. In 2 (6.4%) patients, small epidural hematomas were diagnosed, which did not require surgical treatment. There were only good outcomes (a GOS score of 4 or 5). After surgery, the median Karnofsky index in the STA group was 90±7. In all 31 (100%) patients, the postoperative wound healed by primary intention, without infectious complications and wound liquorrhea. One (4%) patient developed eyebrow palsy; 3 (12%) patients had hypoesthesia in the supraorbital region. The mean VAS score of patient satisfaction with the cosmetic result was 9.36 (median 10±1). The mean follow-up period was 16.2±13.5 months (2-38 months). The STA is adequate for removal of CSR and ACF tumors under proper selection of patients. It provides an adequate view of anatomical structures and enables successful tumor resection through a less traumatic access.

A Rare Case of Spontaneous Pneumocephalus as a Complication of Nontraumatic Nasal Liquorrhea

Pneumocephalus is the ingress of air into the intracranial cavity. Pneumocephalus is associated with several etiological factors, such as head injuries, surgical interventions, infections and neoplasms. With spontaneous nasal liquorrhea, pneumocephalus is extremely rare, since a defect must be large in order to cause it. Clinical implications of pneumocephalus depend on location and volume of air in the cranial cavity. The most common and described symptoms are headache, “splashing sound”, rhinorrhea and otorrhea, meningism, dysfunction of cerebrospinal nerves, hemiparesis, optic disc edema, epileptic seizures, collaptoid states, psychiatric symptoms. For treatment of pneumocephalus, both conservative and surgical methods are used. The choice of tactics depends on type, etiology and volume of the air that has entered the cavity of the skull. In this article, we describe the case of effective treatment of spontaneous nasal liquorrhea, complicated by pneumocephalus and meningitis.

Modern diagnosis and treatment in children with congenital basal encephalocele

The study group included 19 patients with basal encephalocele, aged 2 months to 18 years. Ten (59%) patients were operated on through a transnasal endoscopic approach; 3 (17.5%) patients were operated on through a transcranial approach; 4 (23.5%) patients were operated on using a combined approach: the patients underwent simultaneous elimination of a cranio-orbital region deformity using the basal transcranial approach as well as hernial sac resection and hernioplasty using the transnasal endoscopic approach. Two children had no surgery due to minimal symptoms and a lack of cerebrospinal fluid leak. Application of the algorithms for diagnosis and treatment of encephalocele, suggested by the authors, enabled making the timely diagnose, defining the optimal surgical tactics, and achieving good treatment results. A differentiated approach to the choice of a surgical technique for basal encephalocele, the use of auto-tissues for skull base reconstruction, intraoperative and postoperative lumbar drainage, and simultaneous elimination of deformity of the fronto-naso-orbital region enable avoiding complications and achieving good functional and aesthetic results.

ТРАВМАТИЧЕСКАЯ ПНЕВМОЦЕФАЛИЯ: ЭТИОПАТОГЕНЕЗ, ДИАГНОСТИКА, СПОСОБЫ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ. КЛИНИЧЕСКИЙ ПРИМЕР

Studying an opportunity to optimize the treatment of the patients with severe traumatic brain injuries is a topical issue in modern neurosurgery. Traumatic tension pneumocephalus is one of life-threatening conditions which accompanies severe TBI and is often complicated with posttraumatic liquorrhea and mass effect. Materials and methods. We carried out systematic search in Russian and foreign medical databases (Medline, Russian Science Citation Index, EMedicine, UMKB) concerning our theme. We included the following words in our search request: tension pneumocephalus, mass effect, valve mechanism, treatment. The result of conducted review of literature was writing the clinic lecture, studying current status of the problem of etiopathogenesis, diagnostics and surveillance of the patients with tension pneumocephalus. The article presenas clinical case of successful surgical treatment of a patient with traumatic tension pneumocephalus. Conclusion. There are no uniform standards of urveillance of the patients with tension pneumocephalus. Based on our own experience, we determined that minimally invasive surgery is a method of choice among reconstructive craniofa-cial surgeries in the treatment of patients with traumatic tension pneumocephalus. It decreases the risks of intra- and postoperative complication. Compliance, using external ventricular drainage and repeated lumbar punctures with prevention of inflammatory complications helped stopping nasal liquorrhea and eliminating mass effect which caused absolute regression of neurological signs

A technique of TachoComb application in dura mater reconstruction in surgery for posterior cranial fossa tumors

Liquorrhea is a condition characterized by cerebrospinal fluid (CSF) leakage from the cranial cavity due to injury to the integrity of the dura mater (DM) and bone structures of the skull base. Surgery for posterior cranial fossa (PCF) lesions distinguishes wound CSF leakage when CSF leaks from a surgical wound as well as basal CSF leakage (nasal liquorrhea and, less often, otoliquorrhea). The main cause of basal CSF leakage is injury (including surgical injury) resulting in a defect in the DM and bone structures (cells of the mastoid process in the case of a suboccipital retrosigmoid approach). There are a variety of DM restoration techniques ranging from DM closure or placement of a synthetic or autologous patch to application of various synthetic adhesives in the form of adhesive compositions (Tissucol) and adhesive substances (TachoComb). This article describes the experience with application of a TachoComb® sponge gained at the 5th Clinical Department of the Burdenko Neurosurgical Institute. The study included 176 patients with acoustic neurinomas. At the final stage of surgery, all the patients underwent DM reconstruction with a TachoComb® collagen sponge. CSF leakage occurred in 3 (1.7%) patients, with each of them having Koos grade 4 tumor. One (0.56%) patient had wound liquorrhea, and 2 (1.1%) patients had nasal liquorrhea. CSF leakage was managed by placement of a lumbar drain; postoperative wound revision was not required. Using the TachoComb® sponge for DM reconstruction in PCF surgery is an effective way to prevent postoperative CSF leakage, provided that the algorithm of manipulations described in the article is followed.

Specific aspects of plastic reconstruction of skull base defects with sphenoid sinus localization

The article describes the specific aspects of the combined method of plastic reconstruction of skull base defects in patients with nasal liquorrhea with sphenoid sinus localization. 15 patients with CSF fistula localization in sphenoid sinus underwent this surgery. In 8 cases meningocele was diagnosed. The main advantages of this technique are as follows: good visualization of all sphenoid sinus section, secure plasty of liquor fistula, functionality, preservation of anatomic continuity of nasal cavity and sphenoid sinus.

Endoscopic transsphenoidal resection of pituitary adenomas invading the cavernous sinus

Pituitary adenomas are benign growths that invade the cavernous sinus (CS) in 10-15% of cases. There are different types of microsurgical and endoscopic approaches enabling resection of tumors from the CS cavity that is a relatively small and hard to reach anatomical structure comprising eloquent neurovascular structures. A study group included 97 patients with pituitary adenomas (PAs) invading the CS. PAs were resected using an endoscopic technique: adenomas were resected from the CS cavity through a standard endoscopic endonasal transsphenoidal approach in 62 cases; a lateral extended transsphenoidal endoscopic approach was used in 35 cases. A control group included patients with PAs spreading into the laterosellar region who were operated on using microsurgical extra-intradural (n=14) and transsphenoidal (n=149) approaches. In the study group, the degree of PA invasion into the CS cavity was determined using the Knosp scale. In the study group, total tumor resection was achieved in 49 (50.5%) cases, subtotal resection in 39 (40.2%) cases, and partial resection in 9 (9.3%) patients. In the case of visual disorders (n=70), vision improvement was achieved in 41.4% of cases. Vision deterioration was detected in 11.4% of cases; no vision changes were in 47.1% of cases. Patients (27.8%) who had not had visual impairments before surgery had no negative changes in vision in the postoperative period. The development/augmentation of oculomotor disorders in the study group occurred in 14 (14.4%) cases. In the study group, hormonal remission of the disease in patients with hormone-active PAs was in 26.7% of cases (n=12). There were no cases of nasal liquorrhea, meningitis, and death in the study group. Endoscopic endonasal transsphenoidal resection of PAs invading the CS is a more efficient and safer surgical technique compared to microsurgical techniques (transsphenoidal and extra-intradural approach). The lateral extended transsphenoidal endoscopic approach enables resection of PAs with massive invasion into the CS (Grade III and Grade IV, Knosp scale) and has less postoperative complications compared to the extra-intradural approach (p<0.05).

The prevention and treatment of nasal liquorrhea in transnasal surgery of the base of the skull

The objective of the present study was to estimate the effectiveness of different methods for the reconstruction of defects in the base of the skull. It was shown that the use of the modern technique for this purpose decreases the risk of the development of postoperative complications. The vascularized flaps can be applied to hermetically close defects in the base of the skull during surgery with the use of the extended transnasal approach. It is concluded that the proposed procedure accelerates the healing process and allows the flaps to be used repeatedly if necessary.

Current diagnostic procedures and surgical treatments for nasal liquorrhea

Current diagnostic procedures and surgical treatments for nasal liquorrhea

Cerebrospinal fluid rhinorrhea as a complication of ACTH-secreting pituitary macroadenoma in a patient with morbid obesity

Cushing's disease (CD) is a progressive neuroendocrine disease caused by a pituitary tumor producing excessive amounts of ACTH. In most cases (80-85%) the cause of the disease is a pituitary corticotroph microadenomas (located within the sella, measuring 3–10 mm, rarely multiple microadenomas) and only 15% of cases are presented as corticotroph hyperplasia or pituitary macroadenoma extending beyond the sella. The macroadenomas in CD usually extend suprasellar (10%), infrasellar tumor growth is relatively rare (5%). If the clinical picture is subtle, the symptoms are caused by the development "mass effect" of the tumor as it propagates to the surrounding pituitary structures. Suprasellar growth leads to compression of the optic chiasm with narrowing of visual fields, infrasellar growth destructs the bottom of the sella turcica and may cause nasal cerebrospinal fluid leak, which is dangerous due depressurization of the cranial cavity and its communication with environmental pathogens, development of life-threatening conditions such as meningitis, meningoencephalitis, ventriculitis. Leading life-threatening complications of the CD are infectious and cardiovascular. But in the case of nasal liquorrhea with expansion of the tumor in sphenoid sinus with destruction of the bottom of the sella, there is an immediate threat to the life of the patient. This article presents an example of a patient with morbid obesity and lack of specific clinical manifestations of CD, in whom the diagnosis of disease CD was made on the results of laboratory and instrumental examination, which experienced a spontaneous nasal cerebrospinal fluid leak.

Successful treatment of severe penetrating cranio-cerebral trauma, associated with brain compression

Introduction. Surgical treatment of severe penetrating cranio-cerebral trauma (SCCT) is a complex problem. Basal liquorrhea (BL) at skull base fractures causes high risk of purulent-septic complications. Conservative BL treatment at scull base fractures with many splinters sometimes ineffective. Along with intracranial hypertensia elimination at decompressive craniectomy (DC) performance and mass-centers removing, during primary operation plastics of scull base defects is needed.Methods. In two patients with SCCT during one operation DC and mass-centers removing were performed stage-by-stage, plastics of scull base defects, using autotissue on a feeding stalk and haemostatic sponge with fibrin-trombin covering “Takhokomb” were used. For intracranial hypertension control during operation and after it continuous monitoring of intracranial pressure was used.Results. The use of proposed approach to SCCT treatment allowed to provide control of intracranial pressure after operation and liquorrhea termination, to avoid intracranial purulent-septic complications.Conclusions. Stage-by-stage DC, mass-centers removing and removal and skull base defects plastics during primary operation — is an effective method of surgical treatment of SCCT, combined with brain compression, scull base fractures and profuse nasal liquorrhea.

Observation of successful treatment of penetrating traumatic brain injury followed by nasal liquorrhea for 61 years

An observation of penetrating traumatic brain injury, made by awl in childhood, followed by remittent nasal liquorrhea and purulent meningoencephalitis for 61 years, is given.For diagnosis clarifying biochemical study of nasal secretion, rhinologic study, MRI and CT-cisternography of the brain were performed. Liquor fistula was closed in two stages, ethmoid bone meningocele, causing obturation of left half of the nose, was removed.On the first stage, using transnasal approach, ethmoid bone meningocele was removed, on the next stage liquor fistula was discharged, using transcranial intradural approach. Anterior cranial fossa base defect was closed with temporal muscle fragment and fixed with fibrin-thrombin glue.