Small Cerebrospinal Fluid Leaks Research Articles

"Parachute" Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base.

"Parachute" Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base.

How to Choose? Endoscopic Skull Base Reconstructive Options and Limitations

As endoscopic skull base resections have advanced, appropriate reconstruction has become paramount. The reconstructive options for the skull base include both avascular and vascular grafts. We review these and provide an algorithm for endoscopic skull base reconstruction. One hundred and sixty-six skull base dural defects, reconstructed with an endonasal vascular flap, were examined. As an adjunct, avascular reconstruction techniques are discussed to illustrate all options for endonasal skull base reconstruction. Cerebrospinal fluid (CSF) leak rates are also discussed. Small CSF leaks may be successfully repaired with various avascular grafting techniques. Endoscopic endonasal approaches (EEAs) to the skull base often have larger dural defects with high-flow CSF leaks. Success rates for some EEA procedures utilizing avascular grafts approach 90%, yet in high-flow leak situations, success rates are much lower (50 to 70%). Defect location and complexity guides vascularized flap choice. When nasoseptal flaps are unavailable, anterior/sellar defects are best managed with an endoscopically harvested pericranial flap, whereas clival/posterior defects may be reconstructed with an inferior turbinate or temporoparietal flap. An endonasal skull base reconstruction algorithm was constructed and points to increased use of various vascularized reconstructions for more complex skull base defects.

Fibrin sealant for control of cerebrospinal fluid otorrhea

Cerebrospinal fluid (CSF) otorrhea is a potentially common complication of trauma or surgery involving the temporal bone and skull base. Traditional methods of controlling CSF otorrhea include observation with or without subarachnoid lumbar drainage of CSF, reinforcement of the incision, or surgical exploration with operative obliteration of the drainage pathway. In recent years, fibrin sealants have been demonstrated to prevent intraoperative bleeding and fluid leaks in a variety of surgical specialties. Here we describe 2 cases in which application of fibrin sealant to a CSF fistula resulted in closure of the fistula without requiring surgical exploration or repair. We believe that the in-office use of fibrin sealant is a safe and costeffective method to obliterate small CSF leaks arising from the temporal bone. 2. Case 1 A 54-year-old man presented with a 4-month history of gradually decreasing hearing and increasing tinnitus in his right ear. An audiogram revealed a right profound sensorineural hearing loss with a 0% speech discrimination score. Vestibular testing revealed a right vestibulopathy, with caloric responses of the right ear 44% weaker than those of the left ear. Magnetic resonance imaging scan demonstrated an enhancing mass within the right internal auditory canal consistent with an intracanalicular acoustic neuroma. The patient subsequently underwent resection of the acoustic neuroma through a right translabyrinthine approach. The eustachian tube was packed with a plug of muscle and the incus. The operative cavity was obliterated with an abdominal fat graft, and the lateral aspect of the defect was closed with hydroxyapatite cement. On the evening of postoperative day 1, the patient experienced clear drainage from his right ear canal. A computed tomographic scan of the head was obtained, which showed complete obliteration of the mastoid cavity with fat. There was no evidence of airfluid level to suggest CSF leak, and there was no evidence of ventricular dilation. Examination of the ear failed to demonstrate a tympanic membrane (TM) perforation. The drainage was collected for analysis and subsequently tested positive for the presence of β2-transferrin, indicating a CSF leak. On postoperative day 2, the patient was given stool softeners to prevent straining and was placed on strict bed rest, with the head of his bed at 45°. A lumbar drain was placed and set to midbrain with 50 to 80 cc drainage every 8 hours. Cerebrospinal fluid otorrhea persisted despite a functioning lumbar drain. A microscope was brought to the bedside. Again, no obvious perforation in the TM was identified. The source was thought to be through the medial posterior canal wall near the annulus. The TM was covered with a layer of EpiFilm (Medtronic Xomed Inc, Jacksonville, FL), and the external auditory canal (EAC) was filled with 2 to 3 cc of Tisseel fibrin sealant (Baxter Healthcare Corp, Deerfield, IL). No further otorrhea was noted after these interventions. The lumbar drain was kept at midbrain level for 72 hours, clamped for an additional 24 hours, and then discontinued. There was no further evidence of otorrhea and no evidence of fluid accumulation under the wound. The patient was then discharged home and had no evidence of recurrent CSF leak with more than 4 years of follow-up.

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Collagen sponge repair of small cerebrospinal fluid leaks obviates tissue grafts and cerebrospinal fluid diversion after pituitary surgery.

Repair of a cerebrospinal fluid (CSF) leak created at the time of transsphenoidal surgery typically involves placement of a fat, fascial, or muscle graft and sellar floor reconstruction. In this report, a simplified repair for small, "weeping" CSF leaks using collagen sponge is described. All patients underwent an endonasal transsphenoidal procedure using the operating microscope. At the completion of tumor removal, if a small CSF leak was noted but no obvious large arachnoidal defect was present, a piece of collagen sponge was fashioned to cover the exposed diaphragma sellae. Titanium mesh was then wedged into the intrasellar, extradural space and a larger piece of collagen was placed over the reconstructed sellar floor. Nasal packing was removed within 24 hours. During an 18-month period, 62 consecutive transsphenoidal procedures were performed for tumor removal. Of 20 patients with a small CSF leak (18 pituitary adenomas, 1 Rathke's cleft cyst, and 1 chordoma), all had successful repair with collagen sponge. At follow-up examinations at 1 to 18 months, no patient had required a lumbar drain or had developed meningitis. One other patient had a large intraoperative arachnoidal defect that was unsuccessfully repaired with the collagen sponge technique; in this patient, a second operation was required with a fat graft, sellar floor reconstruction, and lumbar drainage. A simplified repair of small CSF leaks after transsphenoidal surgery using a two-layered collagen sponge technique with sellar floor reinforcement is thought to be safe and effective and obviates the need for tissue grafts, fibrin glue, or lumbar drain placement.

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Frontobasal approach for trauma and tumor.

The potential for remediation of a host of varied disease processes afflicting the skull base has been increasingly realized over the past two decades. Advances in medical technology, the development of new approaches, and most importantly the close cooperation of the head and neck surgeon and the neurological surgeon have made this possible. Surgeons are attempting to diminish the injury to normal un-involved structures while at the same time maximizing exposure and enabling rectification of the disease or disorder. This is especially pertinent in a number of frontobasal approaches used in anterior craniofacial surgery. The osteoplastic flap approach to the posterior wall of the frontal sinus to repair small cerebrospinal fluid leaks and manage posterior wall fractures saves the patient a larger anterior craniotomy and brain retraction. Cranialization of the frontal sinus in comminuted through-and-through fractures allows for removal of devitalized brain, dural repair, and safe management of the frontal sinus. The lateral rhinotomy medial maxillectomy-ethmosphenoidectomy approach coupled with either an osteoplastic flap of the frontal sinus or a low limited craniotomy is an excellent approach for resection of tumors encroaching on the anterior skull base. Even malignancies of this region can be completely excised with adequate margins, yet produce minimal to no facial aesthetic distortion. Moreover, larger tumors requiring a more extensive lip-splitting incision and total maxillectomy with orbital exenteration can often anticipate minimal deformity, especially with good prosthetic rehabilitation. In the resection of aggressive malignancies, techniques of ocular preservation and facial bone sparing have been developed with encouraging cosmetic results.

Endoscopic sinus surgery.

Endoscopic nasal surgery has become the single major advance in the specialty of otolaryngology since the introduction of the operating microscope and middle ear surgery. The value of improved assessment of nasal and sinus pathology using the endoscope diagnostically cannot be overstated. Once pathology is better evaluated, therapy will at least be more appropriate. It is now possible to carry out such nasal surgery as polypectomy, antrostomy and turbinoplasty more accurately and more safely, as well as provide better postoperative care. The use of the endoscope has afforded a useful sub-cranial route for the repair of at least small cerebrospinal fluid leaks, while it is likely that such procedures as dacrocystorhinostomy will eventually be mostly performed using the nasal endoscope. Some orbital decompressions will also be suitable for medial orbitotomy via the endoscope. Additionally, assessment of the extent of extrusion of orbital contents after blow-out injury has been invaluable, as is evaluation of the posterior wall of the frontal sinus after frontal bone trauma. Functional endoscopic sinus surgery (FESS) has an undoubted place in the surgery of frontoethmoidal mucocoeles. While few oncologists would be sanguine about its use in the surgery of nasal tumors, it is still of great value in evaluation and biopsy. Although FESS confined to the osteomeatal complex in the presence of early sinus disease is almost certainly an advance, what is still not proven, is the place of endoscopic sphenoethmoidectomy in the treatment of chronic rhinosinusitis.