Cerebrospinal Fluid Leak Repair Research Articles

Management of coexistent sinonasal pathology in patients undergoing endoscopic cerebrospinal fluid rhinorrhea repair

IntroductionPatients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair. ObjectiveTo study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea MethodsA retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period. ResultsOf a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%). ConclusionPatients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.

The relationship between spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension

Surgical treatment of spontaneous cerebrospinal fluid (CSF) leak is now performed by ENT surgeons, endonasal endoscopy being preferred to craniotomy as less invasive. However, it is often the symptom of underlying idiopathic intracranial hypertension, which lies outside the traditional sphere of ENT competence. Surgery is a necessary step, but should not obscure the need to treat the underlying pathology. This treatment is complex, and requires multidisciplinary team-work between otorhinolaryngologist, ophthalmologist, neurologist, neurosurgeon, radiologist, dietician, endocrinologist and psychotherapist. The present update details this multidisciplinary management to which the ENT surgeons must be attentive before and after spontaneous CSF leak repair.

Outcomes of Central Nervous System Infections Treated by an Outpatient Parenteral Antimicrobial Therapy Program in a Public Teaching Hospital

Background Outpatient parenteral antimicrobial therapy (OPAT) has been safely used to treat a variety of infections. However, limited data are available on the safety and efficacy of OPAT for central nervous system (CNS) infections. Methods This was a retrospective, single-center study evaluating the safety and efficacy of OPAT in patients with CNS infections between July 1, 2009, and May 31, 2016. Demographic, medical, infection-specific, and drug-specific data were collected for each patient. Patients were categorized as clinical cure, probable cure, or treatment failure based on resolution or recurrence of infection for up to 1 year after OPAT completion. Safety of OPAT was evaluated through adverse drug event (ADE) and line complication (LC) monitoring. Readmission rates from OPAT-related ADE and LC were also recorded. Results Forty-seven patients with CNS infections (mean age, 45.3 years; 70.2% male) received OPAT for a median duration of 12 days (range, 2–144 days); 1 patient was excluded from efficacy analysis because of hospice transition. Thirty-seven patients (80.4%) achieved clinical cure, 7 patients (15.2%) had probable cure, and 2 patients (4.3%) experienced treatment failure. Three patients (6.4%) experienced ADE and 4 patients (8.5%) experienced LC during OPAT. Five patients (10.6%) required rehospitalization because of worsening infection (n = 1), LC (n = 2), cerebrospinal fluid leak repair (n = 1), and insurance issues (n = 1). Six patients (12.8%) required a therapy change because of ADE or LC. Conclusions Treating CNS infections with OPAT seems to be safe and effective based on the low failure and complication rates observed in this study.

The sellar barrier on preoperative imaging predicts intraoperative cerebrospinal fluid leak: a prospective multicenter cohort study.

The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery. This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis. Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001). The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.

Cribriform CSF Leak: Endoscopic Surgical Repair Using Free Septal Mucosal Graft Without Postoperative Nasal Packs.

Cribriform plate is the commonest site of Cerebrospinal fluid (CSF) leak, its fragility and juxtaposition of arachnoid's investment to the bone, where the olfactory nerve pierces the skull, is a vulnerable site for CSF leak. Endoscopic transnasal approach has been the main stay for CSF leak repair over the past 2 decades. The technique and surgical steps of Endoscopic Surgical Repair of Cribriform CSF Leak using Free Septal Mucosal Graft without Postoperative Nasal packs are presented. Transnasal endoscopic CSF leak repair under General anesthesia with free mucosal graft, the critical steps include visualize the site of leak, lateralisation of middle turbinate, defect site cauterised with bipolar cautery. Free mucosal from contralateral side of the septum was placed as overlay technique. Graft stabilised with surgicel after ensuring adequate contact between the graft and the defect site. If the defect site is large then fat harvested from thigh is used as bath plug the defect, then free mucosal graft is kept supported by surgicel. Finally the middle turbinate was medialized and sutured with 3 0' Vicryl with nasal septum to support the graft and also to stabilize the middle turbinate as a quilting stich. No fibrin glue was used in our case series. No nasal packing was done. Patients discharged on 2nd or 3rd postoperative day. This technique provides consistent good results reduced operating time of 40min, no post-operative morbidity, early mobilisation, with 100% success rate and with added advantage of no nasal packing, patient can easily breathing through the nose postoperatively & no recurrence on long follow up.

Cerebrospinal Fluid Leak Repair Simulation Model: Face, Content, and Construct Validation.

Cerebrospinal fluid leak (CSFL) repair simulation models are scarce; however, these models are valuable tools for skull base reconstruction surgery training. This study aims to assess the face, content, and construct validity of a CSFL repair simulation model. Eight novices (residents- PGY3) and eight experts have performed skull base reconstruction in multiple sites in twelve human cadaveric heads in simulated surgical environment. The experts completed a post-study 21-item questionnaire to assess the face and content validity. The performances of the participants were recorded and scored by two independent investigators who were blinded to the participant's level. Global Rating Scale of Operative Performance (GRSOP) and a Specific Skull Base Reconstruction Checklist (SBRC) were used to score the performances. The responses from the expert group for the 21-item questionnaire were high for all items (4.13-4.88 out of 5). The internal consistency reliability of the questionnaire and the intraclass correlation, which was derived by Cronbach's Alpha, were 0.913 and 0.941 respectively. Differences in construct validity between the two groups were statistically significant for both the GRSOP and SBRS (P-value < 0.001). We demonstrated the face, content, and construct validity of the CSFL repair simulation model, which facilitates the acquisition of technical skills necessary for skull base reconstruction surgery. The model includes realistic features that make it useful in educational courses.

Early Experience With Telemedicine in Patients Undergoing Otologic/Neurotologic Procedures.

Compare outcomes for patients who were seen via telemedicine visits after otology/neurotology surgical procedures with those who were seen in traditional office visits. Retrospective case review. Tertiary care academic medical center. Inclusion criteria were patients who underwent otologic/neurotologic surgery and were seen in at least one telemedicine visit for postoperative care. Telemedicine visit for postoperative care. Comparison of the number of patient calls, unplanned visits, and delayed complications between telemedicine patients and controls matched for age, procedure, and American Society of Anesthesiologists (ASA) status. Eighteen patients were seen in telemedicine visits postoperatively after the following otologic/neurotologic surgical procedures: cochlear implant surgery (10), vestibular schwannoma resection (4), combined middle fossa and transmastoid cerebrospinal fluid (CSF) leak repair (2), middle fossa repair of superior canal dehiscence (1), and stapedectomy (1). All telehealth visits were for the second postoperative visit. The mean number of patient calls after surgery was 2.3 for the telemedicine group and 1.9 for matched controls which was not a statistically significant difference (p = 0.466). Both groups each had two patients who went to the emergency room, with one in each group being admitted. There was one delayed complication in the control group. Our preliminary experience suggests telemedicine may be used safely in caring for patients after otologic/neurotologic surgery, though it may be associated with more patient phone calls. Further study and experience, including assessing patient satisfaction, will clarify the future role of telemedicine in otology and neurotology.

Cerebrospinal fluid rhinorrhoea: does fibrin glue change the surgical outcome?

Cerebrospinal fluid rhinorrhoea takes place when there is a breakdown of the barriers separating the nasal cavity from the subarachnoid space. The aim of this study was to assess the surgical outcomes of endoscopic transnasal cerebrospinal fluid leak repair with and without fibrin glue. There were 43 patients with cerebrospinal fluid rhinorrhoea who underwent surgery for cerebrospinal fluid leak repair between 2014 and 2018. Patients were divided into group A, where fibrin glue was used, and group B, where fibrin glue was not used. It was found that 74.4 per cent of cases were due to spontaneous cerebrospinal fluid leak. The most common site of a leak was the cribriform plate (65 per cent). There was a success rate of 96.1 per cent (25 of 26) in group A and 83 per cent (15 of 17) in group B. There was no statistically significant difference between the results of the two groups (chi-square test: p = 0.31). There was no statistically significant difference in the results of cerebrospinal fluid leak repair with and without fibrin glue.

Endoscopic management of lateral sphenoid cerebrospinal fluid leaks: Identifying a radiographic parameter for surgical planning.

ObjectiveRepair of cerebrospinal fluid (CSF) leaks of the lateral recess of the sphenoid (LRS) sinus can be challenging to accomplish via an endoscopic transphenoidal approach. The endoscopic transpterygoid approach can improve surgical access to the lateral recess but requires more extensive surgical dissection. We review our experience with LRS CSF leak repair via both techniques to determine whether preoperative radiologic data can help predict the most appropriate surgical approach.MethodsElectronic medical records of patients with LRS CSF leaks were retrospectively reviewed at a single tertiary referral center. Radiographic measurements from preoperative computed tomography images were reviewed.ResultsTwenty‐two LRS CSF leaks were identified. The transphenoidal and transpterygoid approach were used in 6 (27.3%) and 16 (72.7%) cases, respectively.The mean vidian canal to foramen rotundum angle of the repairs accessed transphenoidally as compared to the transptyergoid approach were not significantly different (41.93° ±10.91, 40.72° ±19.49, respectively; P = .63). However, the mean volume of the LRS accessed by the transpterygoid approach was significantly greater compared to those accessed through the transphenoidal approach (0.97 cm3 ± 0.48, 0.39 cm3 ± 0.40, respectively; P = .04). A LRS volume of 0.400 cm3 or greater predicted the use of the transpterygoid approach with 93.3% sensitivity and 60.0% specificity.ConclusionThis study demonstrated that LRS CSF leaks that necessitated repair by the transpterygoid approach, rather than transphenoidal approach, were in the context of significantly larger lateral recess. Assessment of the LRS volume is a quantifiable parameter to aid in preoperative surgical planning.Level of EvidenceLevel 4.

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.

Role of Adjunct Treatments for Idiopathic CSF Leaks After Endoscopic Repair.

A higher incidence of recurrent cerebrospinal fluid (CSF) leaks has been reported with idiopathic CSF leaks. A growing number of institutions advocate for routine use of intracranial pressure-lowering adjunct treatments after endoscopic repair. We report our results in a patient cohort in which only symptomatic patients are subjected to further testing and treatment. Retrospective review. A retrospective review of patients who underwent endoscopic transnasal repair of idiopathic CSF rhinorrhea was performed at the University of Miami, Florida, from July 2010 to July 2017. The database was queried for demographical data, surgical details, radiological findings, and postoperative outcomes. Only patients with greater than a 12-month follow-up were included. Thirty-three patients underwent endoscopic repair of an idiopathic CSF leak. Twenty-six (79%) were females, with an average age of entire study population being 48 years. The average body mass index (BMI) of the cohort was 33 kg/m2 , with 89% being overweight (BMI > 25 kg/m2 ). The skull base defect was found to be mainly at the cribriform plate (64%) and sphenoid sinus (30%). Endoscopic repair was performed successfully as a single repair in 32 patients (97%). The average follow-up was 47 months. Postoperative adjunct medications were used on four patients (12%) with symptomatic idiopathic intracranial hypertension. Endoscopic repair of idiopathic CSF leaks was found to have a high rate of success in our study. Postoperatively, only four patients required additional measures to medically reduce symptomatic intracranial hypertension. Routine postoperative adjunct treatments are unnecessary and may expose patients to adverse long-term side effects. 4 Laryngoscope, 131:41-47, 2021.

Novel Risk Calculator for Suboccipital Decompression for Adult Chiari Malformation

Patient counseling and selection for surgical therapy in adult Chiari malformation type I (CM-1) remain debatable. We aimed to develop a clinical calculator predicting the risk of nonhome discharge and reoperation using the American College of Surgeons-National Surgical Quality Improvement Program database. The database from years 2011 through 2017 was queried to identify the subset of CM-1 patients undergoing suboccipital decompression. Univariable analysis was conducted to identify baseline factors associated with nonhome discharge and 30-day reoperation following the initial decompression procedure. Logistic regression and the Akaike Information Criterion were used to identify the optimal models predictive of both outcomes. Performance was assessed using receiver operating curves and validated with bootstrapping. In 706 CM-1 patients, the rate of nonhome discharge was 5.2% and the reoperation rate was 6.6% with most reoperations consisting of cerebrospinal fluid flow diversion and cerebrospinal fluid leak repair. The optimal model predictive of nonhome discharge consisted of age (odds ratio [OR]= 1.05, P= 0.001), diabetes (OR=2.44, P= 0.080), and American Society of Anesthesiologists class (OR= 1.94, P= 0.082) with an area under the curve of 0.720. The optimal model predictive of reoperation consisted of female sex (OR= 0.48, P=0.031), body mass index (OR= 1.05, P= 0.002), and ASA class (OR= 3.44, P= 0.001) with an area under the curve of 0.726. A calculator for both outcomes was deployed under the following URL: https://jhuspine3.shinyapps.io/Discharge_Reop_Calculator/. We have used a large international database to develop a simple risk calculator based on readily available preoperative variables. Following subsequent validation, this tool can help optimize patient counseling and decision making in adult CM-1.

Reconstruction after endoscopic surgery for skull base malignancies.

The ability to resect malignancies of the ventral skull base using endoscopic endonasal approaches has created a need for effective endoscopic reconstructive techniques. The purpose of this review is to summarize current techniques for reconstruction of large skull base defects during endoscopic endonasal surgery. Recent medical literature was reviewed to identify techniques and best practices for repair of skull base defects during endoscopic endonasal surgery. Preference was given to evidence-based recommendations. Superior results are observed with multilayer inlay/onlay grafts supplemented with vascularized flaps. The nasoseptal flap is the primary reconstructive flap for most defects; secondary choices include the lateral nasal wall flap and extracranial pericranial flap. Clival defects are particularly challenging and are further augmented with adipose tissue to prevent pontine herniation. Perioperative management including the use of lumbar cerebrospinal fluid drainage minimizes the risk of a postoperative leak in high-risk patients. Postoperative cerebrospinal fluid leaks are managed similarly to primary leaks and may require use of a secondary vascularized flap. Complications of reconstructive flaps include flap necrosis and cosmetic nasal deformity. Large defects of the anterior, middle, and posterior cranial fossae can be managed similarly by adhering to basic principles of reconstruction. Future developments will improve stratification of patients into reconstructive groups and allow tailored reconstructive algorithms. New biomaterials may replace autologous tissue and facilitate endoscopic repair. Improved monitoring will allow for assessment of the reconstructive site with early detection and repair of postoperative cerebrospinal fluid leaks.

Audiometric Outcomes and Middle Ear Disease following Cerebrospinal Fluid Leak Repair.

To investigate audiometric outcomes and incidence of chronic ear disease following lateral skull base repair (LSBR) of cerebrospinal fluid (CSF) leaks. Retrospective review. Tertiary skull base center. Consecutive adults undergoing LSBR of CSF leaks between 2012 and 2018 were reviewed. Audiometric data included mean air conduction pure-tone average (PTA), air-bone gap (ABG), speech recognition threshold (SRT), and word recognition score (WRS). The incidence and management of the following were collected: effusion, retraction, otitis media and externa, perforation, and cholesteatoma. Seventy-three patients underwent transmastoid (n = 5), middle cranial fossa (n = 2), or combined approach (n = 67) for repair of spontaneous leaks (sCSFLs, n = 41) and those occurring in the setting of chronic ear disease (ceCSFLs, n = 32). ABG decreased 7.23 dB (P = .01) in sCSFL patients. Perforations (P = .01) were more likely in ceCSFL. No sCSFL patient developed a cholesteatoma, perforation, or infection. Effusions (n = 7) were transient, and retractions (n = 2) were managed conservatively in the sCSFL cohort. Eight ceCSFL patients required tubes, 3 underwent tympanoplasties with (n = 2) and without (n = 1) ossicular chain reconstruction (OCR), and 1 had tympanomastoidectomy with OCR. Lateral skull base repair of CSF leaks maintained or improved hearing. Patients with preexisting chronic ear disease were more likely to require additional intervention to sustain adequate middle ear aeration compared to the sCSFL cohort. LSBR of sCSFL does not appear to increase risk for developing chronic ear disease.

Expanded transnasal approaches to the skull base in the Middle East: Where do we stand?

ABSTRACTBACKGROUND: Endoscopic transnasal surgery has gained rapid global acceptance over the last two decades. The growing literature and understanding of anterior skull base endoscopic anatomy, in addition to new dedicated endoscopic instruments and tools, have helped to expand the use of the transnasal route in skull base surgery.OBJECTIVE: Report our early experience in expanded endoscopic transnasal surgery (EETS) and approach to skull base neoplasms.DESIGN: Descriptive, retrospective case series.SETTING: Major tertiary care center.PATIENTS AND METHODS: A retrospective case review was conducted at King Saud University Medical City between December 2014 and August 2019. Cases with skull base neoplasms that underwent EETS were included. EETS was defined as endoscopic surgical exposure that extended beyond the sellar margins (prechiasmatic sulcus superiorly, clival recess inferiorly, cavernous carotid lines laterally). Routine transsphenoidal pituitary neoplasms, neoplasms of sinonasal origin and meningoencephaloceles were excluded.MAIN OUTCOME MEASURES: Preoperative clinical assessment, imaging results, surgical approach, and hospital course were all retrieved from the patient electronic charts. Clinical follow-up, perioperative complications, and gross residual tumor rates were documented and reviewed.SAMPLE SIZE AND CHARACTERISTICS: 45 cases of EETS, 13 males and 32 females with mean age of 39.0 (17.7) years (range 2–70 years).RESULTS: The series comprised a wide range of pathologies, including giant pituitary adenoma (8 cases), meningioma (23 cases), craniopharyngioma (4 cases), chordoma (4 cases), optic pathway glioma (2 cases), epidermoid neoplasms (2 cases), astrocytoma (1 case), and teratoma (1 case). For the entire series, gross total resection was achieved in 25/45 operations (55.5%). Postoperative cerebrospinal fluid leak was the most common complication observed in 9 patients (20%) which were all managed endoscopically. Major vascular complications occurred in 2 patients (4.4%) and are described. Other complications are outlined as well. No mortality was observed.CONCLUSIONS: EETS to the skull base can be done with results comparable to traditional approaches. More work is needed to expand our experience, improve outcomes, and educate the public and medical community in our region about the usefulness of this approach.LIMITATIONS: Sample size and study design.CONFLICT OF INTEREST: None.

Spontaneous Cerebrospinal Fluid Leak after Initiation of Dopamine Agonist Therapy in Macroprolactinomas: Two Case Reports and a Literature Review

To describe 2 spontaneous cerebrospinal fluid (CSF) leaks complicating treatment of macroprolactinoma (MPRL) with dopamine agonist (DA) therapy. We present the 2 cases of spontaneous, DA-related CSF leaks. Prolactin levels were used to assess hyperprolactinemia. Beta-2 transferrin was tested in rhinorrhea fluid, and magnetic resonance imaging was used to assess the sella. Case 1 was a 45-year-old woman with a history of MPRL, recently started on bromocriptine at 15 mg/day, presented with clear rhinorrhea, headache, and nuchal rigidity. Magnetic resonance imaging showed a large sellar lesion extending into the cavernous sinuses, posterior sphenoid sinuses, and suprasellar cistern. Computed tomography revealed areas concerning for bony erosion, likely representing leak sites, and the rhinorrhea fluid was positive for beta-2 transferrin, confirming the CSF source. Empiric antibiotics for meningitis were given and she underwent urgent neuroendoscopic, transsphenoidal CSF leak repair and debulking of the pituitary mass. Case 2 was a 55-year-old man with a 10-year history of untreated MPRL who was started on bromocriptine at 5 mg/day 2 weeks prior to admission. He presented with clear rhinorrhea and a metallic taste in his mouth, worse with the Valsalva maneuver. Imaging confirmed clinical suspicion and he was taken for surgery. A high-flow CSF leak was encountered once the tumor was debulked. This was repaired with an abdominal fat pad graft. Both patients developed diabetes insipidus and required postoperative adjuvant DA therapy. Spontaneous CSF leaks can complicate medical therapy of large MPRL with underlying skull defects, typically within weeks of initiation of DA. This should prompt clinicians to educate patients about the symptoms of potential CSF rhinorrhea and encourage them to promptly report them.

Frontal sinus fractures and cerebrospinal fluid leaks: a change in surgical paradigm.

Traditionally, frontal sinus trauma has been treated using open incisions to access the anterior and/or posterior table. Mounting evidence indicates frontal sinus trauma can be managed using an endoscopic endonasal approach (EEA) with less morbidity. Such an approach permits preservation of a functional sinus and less reliance on computed tomography for postoperative follow up. The goal of this article is to highlight a shift in paradigm away from open approaches using external incisions towards an EEA to repair cerebrospinal fluid (CSF) leaks and fractures of the frontal sinus. In a prospective case series of 46 patients undergoing EEA to frontal sinus fractures, 41 patients had active CSF leaks arising from the posterior table of the frontal sinus. A successful endoscopic repair was achieved in 97.6% with only one patient requiring revision Draf IIB surgery. Anterior table fractures were also successfully reduced with excellent cosmesis. Endoscopic repair of frontal sinus fractures and CSF leaks is effective and well tolerated. In select patients, it is the preferred treatment as it maintains normal sinus structure and function, minimizing both early and late complications.

Comparison of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks From the Middle and Posterior Fossa.

To compare patients surgically managed for spontaneous cerebrospinal fluid (CSF) leaks of the temporal bone arising from the middle cranial fossa (MCF) and posterior cranial fossa (PCF) and to describe the surgical management of posterior fossa CSF leaks. Retrospective case review. Academic tertiary center. Adult patients presenting with spontaneous temporal bone CSF leaks undergoing operative repair between January 2010 and August 2018. Patients with a history of trauma, previous mastoid surgery, and iatrogenic CSF leaks were excluded. Transmastoid or MCF CSF leak repair. Patient demographics, body mass index (BMI), comorbidities, presenting features, and lumbar puncture opening pressures were compared between groups and the management of the PCF CSF leaks described. Forty-six patients (26 women, 20 men) were included. The mean age at the time of repair was 58.0 ± 12.9 years (±SD). The origin of the CSF leak was from the PCF in three patients and MCF in 43 patients. All three patients with PCF leaks presented with an acute history of meningitis compared with only seven (16%) in the MCF group. This difference was statistically significant (p = 0.01, Fisher's exact test). There were no statistically significant differences in age, sex, BMI, or lumbar puncture opening pressures. The PCF leaks were repaired using a transmastoid approach with multilayer closure of the bony defect and fat graft obliteration of the mastoid. Spontaneous CSF leaks arising from the PCF are rare and may present more commonly with meningitis. Identification requires careful review of imaging.

Prognostic factors affecting success rate in endoscopic management of spontaneous cerebrospinal fluid rhinorrhea

Objective Endoscopic sinus surgery has been established as the standard procedure for management of most cases of cerebrospinal fluid (CSF) rhinorrhea and meningoceles. Spontaneous leak represents the most common etiology, whether it is associated with idiopathic intracranial hypertension or not. Nevertheless, results of endoscopic repair of spontaneous CSF leaks represent the worst among other nonspontaneous etiologies in most literatures, with a wide range of success (25–87%). Patients and methods This is a retrospective study that included 52 cases of spontaneous CSF leak, which had been managed by endoscopic sinus surgery, in the last 8 years, in Kasr Alaini Hospital, Faculty of Medicine, Cairo University, and Shebin Alkom Teaching Hospital; and also some cases were done in New Kasr Alaini Teaching Hospital. Data collected included age, sex, manifestations of high intra cranial tension (ICT), duration of leak, site, method of repair, and whether repair was successful or not. Results In 52 cases with spontaneous CSF leak, successful repair was achieved in 73% (38 out of 52). There were 41 (78.8%) female and 11 (21.2%) male patients. Success in female patients was 70.7% (29 of 41 cases), and success in male patients was 81.8% (9 of 11 cases). Manifestations of increased ICT were found in 17 of 52 cases (32%), where nine of them failed (52%). Leaks in the ethmoidal region represented 27 (52%) cases, sphenoidal region 19 (36.5%) cases, and frontal region six (11.5%) cases. There were three methods of repair: in the first group, repair was done with fat and overlay mucosal graft in 17 (33%) cases; in the second group, repair was done with under lay epidural graft plus overlay mucosal graft in 29 (56%) cases; and in the third group, an underlay graft was used, and in addition, an overlay septal flap was put in six (11%) cases. Conclusion Spontaneous CSF leak represents a common cause of CSF rhinorrhea. Success rate is in general lower than in other etiologies of CSF leaks. The outcome of the surgical intervention could be related to variable demographic and preoperative factors.

Challenges and controversies in endoscopic management of cerebrospinal fluid rhinorrhea

Introduction Endoscopic management of cerebrospinal fluid (CSF) rhinorrhea is considered by many as the ideal approach due to its low morbidity and higher closure rate. However, many challenges and controversies are still reported. Objective The aim was to discuss the challenges of endonasal repair of CSF leaks and controversies regarding the use of intrathecal fluorescein (ITF) and the number of graft layers. Materials and methods This retrospective study included 30 patients who had had endoscopic repair for their CSF rhinorrhea in our institute between July 2015 and June 2017. Fifteen (50%) patients were managed using the two-layer repair without ITF injection (group I), while the remaining were managed using three or more graft layers and ITF (group II). Results The study included 30 patients: 17 (57%) women and 13 (43%) men. Their age ranged from 4 to 68 years with mean ± SD = 38 ± 15.86 years. Eighteen cases presented with spontaneous leaks (nine of them had normal CSF pressure). Four (13.3%) cases had defects in the posterior wall of the frontal sinus while other defects involved the fovea ethmoidalis, lateral lamella, and the cribriform plate of the ethmoid. Success rate was equal in both groups (93%). Conclusion Endoscopic management of CSF rhinorrhea has many challenges including repair in the pediatric population and anatomical areas with difficult accessibility, for example, frontal sinus leaks. It requires good endoscopic visualization and endoscopic instrumentation facilities in addition to experienced surgical hands. Double-layer repair and avoidance of ITF show the same success rate as other more time-consuming strategies with life-threatening complications.