Repair Of Cerebrospinal Fluid Fistula Research Articles

Endonasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhoea: The Birmingham UK experience.

Spontaneous cerebrospinal fluid (CSF) leaks (SCSFL) occur in the absence of trauma, surgery, or underlying intracranial pathology. They represent a significant healthcare burden on patients with complications such as meningitis. We present our experience of SCSFL repair via the endonasal endoscopic approach. All patients who underwent CSF fistula repair at a tertiary UK hospital, between 1st January 2012 to 31st December 2019, were identified and had their case notes analyzed retrospectively. There were 33 patients included consisting of 27 (81.8%) females, with age range from 31 to 81 years (mean 55.2). Mean body mass index (BMI) was 35.2kg/m2 , with 32 (97.0%) patients overweight (BMI >25). All patients presented with intermittent watery rhinorrhoea and had a positive biochemical analysis. Computed tomography (CT) and/or magnetic resonance imaging (MRI) identified leak sites in 29 patients (87.9%). The most common intraoperative defect site was the cribriform plate (42.4%). A variety of closing techniques were used including onlay grafts (72.7%), tissue glue (87.9%), nasoseptal flaps (63.6%), mucosal free grafts (21.2%), fat grafts (21.2%), and additional support materials (87.9%). Nasal packing was used in all patients. The average length of stay was 1.6 days. Postoperative complications occurred in two patients (6.1%) (meningitis, epistaxis). Overall, there was a successful primary repair in 32 (97.0%) patients with most cases employing a multilayered reconstruction method (78.8%). Our results demonstrate excellent success rates with the endoscopic endonasal approach to SCSFL. This adds to the literature by demonstrating a detailed analysis of the experience in SCSFL management in one of the largest UK centres.

Three-Dimensional Immersive Photorealistic Layered Dissection of Superficial and Deep Back Muscles: Anatomical Study

IntroductionThe distinct anatomy of the superficial and deep back muscles is characterized by complex layered courses, fascial planes, specific vascularization, and innervation. Knowledge of these anatomical parameters is important for some surgical approaches, including lumbar disc herniation, cerebrospinal fluid fistula repair, vascularized muscle pedicle flaps, and posterior fossa extra-intracranial bypass. In the present study, we use modern techniques of three-dimensional (3D) surface scanning to help better illustrate the layered anatomy of the back muscles.Material and methodsWe dissected in layers the back muscles of one cadaver. Every step of the dissection was 3D scanned using a technique called photogrammetry, which allows the extraction of 3D data from 2D photographs. The 3D data were processed using Blender software, and the 3D photorealistic models were uploaded to a dedicated website for 3D visualization. This allows users to see the 3D models from every desktop or mobile device, as well as augmented (AR) and virtual reality (VR) formats.ResultsThe photorealistic 3D models present the back muscles' anatomy in a volumetric manner, which can be visualized on any computer device. The web 3D features, including AR and VR, allow users to zoom, pan, and rotate the models, which may facilitate learning.ConclusionThe technology of photorealistic surface scanning, modern 3D visualization possibilities of web-dedicated formats, as well as advances in AR and VR, have the potential to help with a better understanding of complex anatomy. We believe that this opens the field for further research in the field of medical education.

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.

Single Layer and Double Layer Duraplasty for the Management of Persistent Cerebrospinal Fluid Rhinorrhea Following Frontal Sinus Trauma: A Retrospective Study.

Persistent cerebrospinal fluid (CSF) rhinorrhea is an infrequent complication of frontal sinus trauma. It often require craniotomy for dural repair and obliteration of sinus with well vascularized pericranial flap. The multilayer vascularized techniques have gained popularity over the years owing to low rate of postoperative CSF leaks. The study retrospectively analyzed 25 frontal sinus trauma patients (20 males, 5 females) of mean age 32 ± 10.23 years with persistent CSF rhinorrhea from January 2011 to December 2018. All patients underwent frontal craniotomy and duraplasty was done with pericranial flap alone in 14 patients (Group I) and in combination with fascia lata graft in 11 patients (Group II). The clinical outcomes of single and double layer dural reconstruction techniques in management of CSF leak were analyzed. The size of defects ranged between 3 to 28 mm. Significant association was present between defect size and reconstruction technique with large defects underwent double layer repair. Two patients developed CSF leak following repair with pericranial flap alone. The rate of successful closure of CSF fistula was 100% with double layer reconstruction technique. However, statistically no significant association was noted between postoperative CSF leak and reconstruction technique. There was no evidence of meningitis, subdural hematoma, intracranial abscess, and mucocele formation in all patients during follow-up of 50.7 ± 23.6 months. To conclude, pericranial flap is a reliable reconstruction material for management of post traumatic frontal sinus CSF leaks. Dual flap technique that combine the use of fascia lata provides comprehensive solution of CSF fistula repair.

The efficacy of an endoscopic endonasal approach in the repair of cerebrospinal fluid fistula: a clinical analysis

<p class="abstract"><strong>Background:</strong> Cerebrospinal fluid (CSF) fistula is an abnormal CSF leakage due to bone and/or dural defect of the skull base and usually operated with endonasal endoscopic approach. The aim of this study was to determine the efficacy of an endonasal endoscopic approach in the repair of CSF leakage and to find the reasons of the recurrence of endoscopic procedure.</p><p class="abstract"><strong>Methods:</strong> The medical records of 24 patients that presented with the diagnosis of cerebrospinal fluid fistula and who had undergone endonasal endoscopic repair surgery were reviewed retrospectively. </p><p class="abstract"><strong>Results:</strong> 13 patients (54.2%) were found to have spontaneous CSF fistulas without any history of trauma, while 11 patients (45.8%) had posttraumatic CSF fistulas. The mean body mass index (BMI) of patients was 31. 3 kg/m² (20.1-49.6). Nasal septal cartilage was used as a graft material in 19 patients (79%) while only fascia was used in 5 patients (21%). The evaluation of long-term results revealed recurrence in 4 patients (16.6%). Two of these patients required a second surgical repair.</p><p class="abstract"><strong>Conclusions:</strong> An endoscopic endonasal approach is a safe method with less morbidity and a reliable outcome in the repair of CSF fistulas. The most important causative factors in the recurrence of endoscopic repair of CSF leak might be to have high BMI and not to use multilayered graft material for closure of fistula.</p><p class="abstract"> </p>

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P128. Surgery for sacral perineural cysts: cold facts of the so-called Tarlov cysts

BACKGROUND CONTEXT Surgical intervention for sacral perineural cysts remains controversial. Although the exact pathophysiology is unknown, it may include a direct communication between the cyst and thecal sac resulting in trapping of cerebrospinal fluid (CSF) due to a valve mechanism. In consequence, microsurgical treatment was directed towards a cohort of patients with large cysts treated with different strategies depending on their intraoperative findings. PURPOSE To evaluate outcome in Tarlov syst surgery comparing two different technques. STUDY DESIGN/SETTING Retrospective comparative multicentre European. PATIENT SAMPLE In 31 consecutive patients (22 female and 9 male). OUTCOME MEASURES Visual analogic scale preop and postop, spine MRI preop and postop, EMG preop and postop. METHODS In 31 cases MRI revealed sacral perineural cysts of at least the size of the S1 vertebral body. All patients had previously received at least a year of conservative modalities. Depending on the cyst anatomy, 20 patients underwent cyst fenestration and wall imbrication while eleven patients underwent cyst fenestration and CSF communication was located and repaired. A total of 27 patients had intraoperative EMG monitoring. Symptoms at initial presentation included aggravated lumbosacral pain, pseudoradicular symptoms, perineal pain and urinary dysfunction. Mean follow-up was 23±5 months. Imaging and clinical follow-up examinations were analyzed. RESULTS Patients were divided in algic and nonalgic symptom relief: while all patients improved their perineal pain and urinary dysfunction only eleven patients reported lasting pain control following surgery. Two patients had previously cyst puncturing and embolization. Three patients underwent additional surgery: one early CSF fistula repair and two deferred refenestration with cerebrospinal fluid tamponade. One patient underwent later an L5-S1 arthrodesis. Three patients experienced internal CSF fistula that were treated conservatively. Successful fenestration and collapse of the cyst revealed by postoperative MRI was evident in 27 cases. Postoperative EMG showed improvement in 22 cases. CONCLUSIONS Direct surgical approach of sacral perineural cysts to the thecal sac is a feasible option in patients with fairly large symptomatic cysts. Partial cyst removal and closure repair for prevention of CSF communication appeared simple and equally effective. Intraoperative EMG monitoring was of particular help regarding cyst wall anatomy. Advice should be given to patients regarding expectations for pain improvement after surgery.

The advantages of using auto-fat tissue in the reconstruction of defects of the skull base in patients with CSF leak

Relevance: At present, the method of repair of the cerebrospinal fluid fistula using mucous flaps according to the “overlay” technique is widely used in the reconstruction of the skull base and is generally accepted. We have developed an original method for reconstructing defects of the skull base in the presence of a cerebrospinal fluid fistula, using an auto-fat tissue and placing it in two layers. Objectives: To conduct a comparative assessment of methods for the reconstruction of the skull base defect in patients with CSF leak using endoscopic endonasal approach. Materials and methods: Under our supervision there were 46 patients with CSF leak. Depending on the technique of cerebrospinal fluid fistula repair, all patients were divided into 2 groups. The first group of 20 patients consisted of patients who underwent surgery with auto-fat tissue according to our proposed technique. The second group - 26 patients were patients who underwent repair of the skull base defect using the standard overlay technique - a mucous flap on the feeding vascular pedicle. The criterion for evaluating the effectiveness of surgical treatment was patient complaints and data from objective research methods (endoscopic examination of the nasal cavity). Results: After 3 months after surgical treatment, a patient of group 1 had a recurrence of liquorrhea, patients of group 2 after 3 months had a recurrence of liquorrhea in 3 patients, after 6 months in 2 patients of group 2 there was a recurrence of liquorrhea. Findings: When the size of the bone defect of the base of the skull is up to 0.6 cm, the original technique proposed by us for plastics of the cerebrospinal fluid fistula with an auto-fat tissue in two layers provides a tight closure of the bone defect and the defect of the dura mater. When using this method of plastics, the risk of the development of a recurrence of CSF leak is significantly reduced in comparison with the plastics of the cerebrospinal fluid fistula with the use of overlay grafts.

Endoscopic repair of cerebrospinal fluid rhinorrhea

IntroductionNasal liquorrhea indicates a cerebrospinal fluid fistula, an open communication between the intracranial cerebrospinal fluid and the nasal cavity. It can be traumatic and spontaneous. ObjectiveThe aim of this study was to assess the outcome of endoscopic repair of cerebrospinal fluid fistula using fluorescein. MethodsThis retrospective study included 30 patients of both sexes, with a mean age of 48.7 years, treated in the period from 2007 to 2015. All patients underwent lumbar administration of 5% sodium fluorescein solution preoperatively. Fistula was closed using three-layer graft and fibrin glue. ResultsCerebrospinal fluid fistulas were commonly located in the ethmoid (37%) and sphenoid sinus (33%). Most patients presented with traumatic cerebrospinal fluid fistulas (2/3 of patients). The reported success rate for the first repair attempt was 97%. Complications occurred in three patients: one patient presented with acute hydrocephalus, one with reversible encephalopathy syndrome on the fifth postoperative day with bilateral loss of vision, and one patient was diagnosed with hydrocephalus two years after the repair of cerebrospinal fluid fistula. ConclusionEndoscopic diagnosis and repair of cerebrospinal fluid fistulas using fluorescein intrathecally has high success rate and low complication rate.

Endoscopic Transnasal Management of Cerebrospinal Fluid Rhinorrhea: Early Experience

Background: Cerebrospinal fluid (CSF) rhinorrhea results from abnormal communication between the subarachnoid space and the nasal cavities. During the last two decades the surgical management of anterior skull base fistulae has evolved from intracranial craniotomy to endoscopic transnasal repair with a high success rate and decreased morbidity. We recently changed our policy and repair CSF rhinorrhea through an endoscopic endonasal approach. The purpose of this work is to describe the technique used for watertight closure of CSF leak along the anterior skull base and to evaluate our early results. Methods: A prospective acquired database of all patients having undergone endonasal endoscopic repair of CSF leaks over a 20-month period at Military Hospital of Tunis starting in March, 2012 was reviewed. Results: A total of 20 patients underwent endoscopic repair of CSF fistula. The etiology was traumatic in 7 cases, spontaneous in 11, and iatrogenic in 2 associated with previous transsphenoidal pituitary surgery. A total of 19 patients had successful primary endoscopic repair of the CSF leak. One patient required a revision surgery due to early failure of the repair and the leak was plugged successfully on the second attempt. We experienced a single case of meningitis during the postoperative course. Conclusion: The overall success rate (100%) and low morbidity in this short series support endoscopic approach as standard of care for CSF leak closure.

Repair of Cerebrospinal Fluid Fistula from an Invasive Skull Base Prolactinoma Using a Septal Mucosal Vascularized Flap: Technical Case Report

Repair of spontaneous cerebrospinal fluid (CSF) fistulas in patients with invasive skull base prolactinomas represents a surgical challenge because of the many sites of potential leak around the tumor and the possibility of developing additional sites of leak as the tumor regresses on dopamine agonist therapy. Little has been published on effective methods for treating this problem. In this case, a vascularized nasoseptal flap was used to repair a spontaneous CSF leak in a 31-year-old male with an invasive prolactinoma who was commenced on dopamine agonist therapy. The patient underwent successful multilayer repair of the fistula with a nasoseptal vascularized flap and abdominal rectus fascia. After 3 months of follow-up, he has had no CSF leak. CSF fistulas caused by skull base prolactinomas can be repaired successfully using a vascularized nasoseptal flap. Long-term follow-up will determine the durability of this repair technique.

Transnasal Endoscopic Repair of Post-traumatic Cerebrospinal Fluid Fistula and Meningoencephalocele: Successful Closure of a Big Breach (18 × 15 mm) with Septal Cartilage and Temporalis Fascia

ABSTRACT Transnasal endoscopic repair of cerebrospinal fluid fistula is recommended for patients with post-traumatic cerebrospinal fluid leaks who do not respond to conservative treatment. It is a safer and more successful alternative to transcranial surgery. We present our experience of using septal cartilage and temporalis fascia in this transnasal endoscopic approach for the repair of the large defect of anterior skull base cerebrospinal fistula and meningoencephalocele. Use of microdebrider is highlighted in the technique for the debridement of the encephalocele and complete exposure of the defect.

Management of unexpected cerebrospinal fluid leak during endoscopic sinus surgery

Cerebrospinal fluid leak during endoscopic sinus surgery is a potentially devastating complication; however, identification and appropriate management can prevent unfavorable outcomes. The purpose of this review is to outline the recent advances in the management of cerebrospinal fluid leaks that occur during endoscopic sinus surgery. The low incidence of this complication makes prospective and randomized study difficult. The expanding role for endoscopic skull base surgery has brought new techniques and advances in the treatment of skull base reconstruction and cerebrospinal fluid fistula repair that can be applied to intraoperative leaks that occur during sinus surgery. Recent reports have focused on the prevention, identification, repair materials, repair technique, and infectious sequelae related to this complication. Several successful techniques that utilize a variety of materials are available for the repair of cerebrospinal fluid leaks encountered during sinus surgery. The clinical scenario will determine the appropriate use of repair material, technique, and postoperative care.

Osteoplastic Frontal Sinusotomy and Extradural Microsurgical Repair of Traumatic Frontobasal Cerebrospinal Fluid Fistulas

The choice of the surgical approach and operative technique for the management of cerebrospinal fluid (CSF) fistulas of the anterior cranial fossa are still a controversially discussed topic. Although “extracranial” approaches through the paranasal sinuses are becoming increasingly more popular among otolaryngologists and maxillo-facial surgeons, most neurosurgeons traditionally prefer the “intracranial” repair of CSF fistulas by a craniotomy.

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

Endoscopic Endonasal Repair of Cerebrospinal Fluid Rhinorrhea by The Combined Overlay and Underlay Techniques

26 J Kor Neurotraumatol Soc Cerebrospinal fluid (CSF) rhinorrhea involves a breakdown of all barriers that separate the subarachnoid space from the upper aerodigestive tract, namely, the mucosa of the nasal cavity or paranasal sinus, skull base, dura mater, and arachnoid membrane. CSF rhinorrhea expressed as meningitis, subdural empyema or brain abscess, when inadequately treated 3,19) . CSF fistulas can be classified into traumatic and non-traumatic: the traumatic group can be classified in accidental and iatrogenic 16) . The non-traumatic group is related with brain tumors, congenital skull base defect and meningoceles or meningoencephaloceles. Conservative treatment is based on bed rest, lumbar punctures and permanent spinal fluid diversion. The surgical treatment of a CSF fistula is controversial as it depends on the etiology of leak and the location of the fistula 15) . Surgical repair consists of transcranial approaches or nasal approaches with the use of an endoscope 1,3,19) . The success rate of transcranial approaches ranged from 60 90%. In recent years, endoscopic methods for the repair of CSF fistula are considered to be the treatment of choice for CSF rhinorrhea repair 9,15) . The advantages associated with the use of an endoscope better lighting, magnification of the image and best angle visualization give the surgeon a more precise diagnosis and a less invasive method of treatment 11,14,17,23) . The aim of this study is to determine the efficacy of endoscopic transnasal repair of cerebrospinal fluid rhinorrhea and skull base defect by the combined overlay and underlay techniques.

Transnasal Endoscopic Repair of Cerebrospinal Fluid Fistulas and Encephaloceles: Surgical Indications and Complications

Transnasal endoscopic repair of cerebrospinal fluid (CSF) fistulas is recommended for patients with CSF leaks who do not respond to conservative treatment. It is a safer and more successful alternative to transcranial surgery. We present our experience on using transnasal endoscopy for the repair of anterior skull base cerebrospinal fluid fistulas. Between 1999 and 2003 we observed 20 patients with CSF rhinorrhea. The etiology was heterogeneous: post-traumatic in 6 cases, iatrogenic in 6 cases (one interesting case of meningioma of the sphenoethmoid plate), dysembryogenetic - due to encephaloceles - in 4 patients (one with Cruzon syndrome and one with Down syndrome) and idiopathic in the other 4 patients. Use of a rigid transnasal endoscope allowed the localization and repair of all fistulas, with the use of fluorescein in 6 cases. Different grafts were used, in particular fat, bone or chondral septum with mucoperiosteum or perichondral mucosa. Generally the graft was inserted with the underlay or the sandwich technique. Lumbar drainage was used in the postoperative period only in 6 cases. No antibiotic prophylactic therapy was used. Endoscopy was successful in 90 % of patients at the first attempt, and in 95 % of patients at the second approach. We had two late complications such as infections. In one child with a post-traumatic fistula and shunt for hydrocephalus, we observed meningitis 2 years after the first endoscopic surgery and he underwent both transnasal endoscopic surgery and transcranial surgery. The second patient was a woman with a spontaneous fistula, who had rhinoliquorrhea three years after the first surgical treatment. During surgery a strange similar purulent material filling the submucous space of the ethmoid roof was found, suggestive for an intranasal abscess that was removed. We did not see any complications such as hematomas or seizures. The follow-up (range: 6 months to 3 years) made both with MRI and rhinoscopy has not shown any relapse until now in 19 of 20 patients treated only with endoscopy. The endoscopic approach is highly effective and safe in the treatment of CSF fistulas, with great visualization and minimal invasiveness, for which it is associated to a very low morbidity. The fluorescein technique is extremely helpful for the diagnosis and surgery of CSF leaks.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair

Background The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. Methods A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. Results Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. Conclusions Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Endoscopic transnasal intradural repair of anterior skull base cerebrospinal fluid fistulae

This study presents the techniques and results of endoscopic diagnosis and repair of cerebrospinal fluid (CSF) fistulae involving the anterior skull base and paranasal sinuses. Design. A retrospective cohort study of all consecutive patients undergoing endoscopic repair of anterior skull base CSF fistulae. Setting. Tertiary referral institutions. Materials and methods. Fifty-two patients underwent endoscopic repair of CSF fistula. Thirteen cases were traumatic in origin, 11 spontaneous not associated with meningoencephalocele and 12 with meningoencephalocele. Eleven were iatrogenic and five associated with transphenoidal pituitary surgery, two acute and three delayed following radiotherapy. The average age of patients was 43 and the male to female ratio was 2:1. A variety of techniques were used to repair the dural defect. In the majority of cases placement of a fat plug on the intracranial surface of the dura was performed. Results. Forty-seven of the 52 patients had successful primary endoscopic repair of the CSF fistula and skull base defect. Five patients required a repeat procedure due to early failure of the repair. After an average follow-up of 27 months no patient has had any recurrence of leak giving a primary closure success rate of 90% and secondary closure rate of 100%. Conclusions. The endoscopic transnasal approach for repair of anterior skull base CSF fistula is a reliable technique and is now the procedure of choice for patients presenting with this problem.

Management of sphenoid sinus cerebrospinal fluid rhinorrhea: Making use of an extended approach to the sphenoid sinus

Objectives: Specific information addressing the management of cerebrospinal fluid (CSF) fistulas that originate from within the sphenoid sinus remains scant. The objective of this study was to review the cause and management of CSF rhinorrhea arising from the sphenoid sinus. Study Design and Setting: This is a retrospective chart review of 12 cases of CSF rhinorrhea arising from the sphenoid sinus that occurred in 11 patients. All patients were treated at a single institution between 1994 and 1999. Results: All patients were managed surgically with sphenoid sinus fat obliteration using an endoscopic sublabial, transseptal approach. This approach was successful for all 12 cases, with median duration of follow-up of 18 months. Conclusions: Endoscopically assisted transseptal repair of CSF fistulas that originate within the sphenoid sinus offers an alternate approach to previously described methods of repair in this region. Advantages include wide access to the entire sphenoid sinus, improved access to laterally pneumatized regions within the sphenoid sinus, and rostral mucosal closure over the repair within the sinus. (Otolaryngol Head Neck Surg 2002;126:147-53.)

Osteoplastic frontal sinusotomy and extradural microsurgical repair of frontobasal cerebrospinal fluid fistulas.

The choice of the surgical approach and operative technique for the management of cerebrospinal fluid (CSF) fistulas of the anterior cranial fossa are still a controversially discussed topic. Although "extracranial" approaches through the paranasal sinuses are becoming increasingly more popular among otolaryngologists and maxillo-facial surgeons, most neurosurgeons traditionally prefer the "intracranial" repair of CSF fistulas by a craniotomy. We present an approach through the frontal sinus for the repair of dural defects behind the posterior wall of the frontal sinus and at the floor of the anterior cranial fossa. The operative procedure comprises the following main steps: 1) exposure of the anterior wall of the frontal sinus by a bicoronal incision; 2) excision of the anterior wall without frontal burr holes; 3) bilateral removal of the posterior wall of the frontal sinus; 4) extradural inspection of the dura behind the frontal sinus and above the cribriform plate, ethmoidal roof, and orbital roof bilaterally; 5) closure of dural tears by direct suture and a periosteal graft; 6) reinsertion of the anterior wall of the frontal sinus and fixation with titanium micro plates. Twenty-five patients operated upon using this technique are described. The aetiology of the frontobasal lesion was traumatic in 23, and an ethmoid carcinoma in two. In all patients, the dural fistulas were successfully repaired during the initial procedure. One patient died from sudden circulatory arrest after an uneventful postoperative course of nine days. Otherwise, there were no postoperative complications. This technique affords atraumatic extradural inspection and repair of dural fistulas bilaterally behind the frontal sinus, and above the cribriform plate and the ethmoidal and orbital roofs with none or minimal brain retraction. It therefore allows early repair of CSF fistulas also in patients with severe brain injury. Although we consider the extradural closure of fistulas the method of choice, this approach also allows for a combined extradural-intradural procedure, thus enabling the surgeon to treat associated intradural pathologies, such as traumatic lesions or tumours of the frontal cranial base.