Spontaneous CSF Rhinorrhea Research Articles

Potential of observing the diameter of the optic nerve sheath using computed tomography in diagnosing high intracranial pressure in patients with spontaneous CSF rhinorrhea.

Spontaneous cerebrospinal fluid rhinorrhea (sCSFR) is often accompanied by an increase in intracranial pressure (ICP). The widening of optic nerve sheath diameter (ONSD) is an indicator of increased ICP. Using CT to measure ONSD is a simple and noninvasive auxiliary method for determining high ICP in sCSFR patients.

A Rare Case of Tension Pneumocephalus with Spontaneous CSF Rhinorrhea Managed by Endoscopic Trans-Sphenoidal CSF Leak Repair.

Tension Pneumocephalus and spontaneous CSF rhinorrhea are very rare associations in clinical practice. We report a case of 65years old male with clear rhinorrhea, severe frontal headache, vomiting and lethargy for a week. MR Cisternography and CT Paranasal sinuses showed significant Tension Pneumocephalus with defect in the posterior wall of sphenoid sinus and CSF pooling in the sphenoid sinus. Endoscopic trans-sphenoidal CSF leak repair was done without any delay followed by complete resolution of Tension Pneumocephalus with in 4 post op days. Prompt precise diagnosis and early intervention of Tension Pneumocephalus is vital to avoid neurological complications.

CSF rhinorrhea: non-contrast CT, contrast-enhanced CT cisternography or combined?

BackgroundRadiologic diagnosis of CSF leaks is challenging. We evaluated the diagnostic value of non-contrast CT and contrast-enhanced CT cisternography in identifying the presence of CSF rhinorrhea and site of leak as well as comparing them to surgical data and/or clinical follow-up.ResultsFifty patients (20 males and 30 females) were included in our study with age ranging from 19 to 67 years. 76% of cases had spontaneous CSF rhinorrhea. Cribriform plate defect was the most common site of CSF leak, accounting for about 50% of cases. The highest sensitivity, specificity, PPV and NPV for diagnosis of CSF rhinorrhea were observed with the combined NCCT and CECTC with values 87%, 100%, 100% and 67%, respectively.ConclusionAccurate surgical planning and successful dural repair requires accurate localization of the dural and osseous defects. CT cisternography which already involves pre-cisternography non-contrast images holds great sensitivity in detection of the exact defect site together with confirmation of the CSF leak.

Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study.

Based on their clinical and radiological patterns, idiopathic CSF rhinorrhea and idiopathic intracranial hypertension can represent different clinical expressions of the same underlying pathological process. Transverse sinus stenoses are associated with both diseases, resulting in eventual restriction of the venous CSF outflow pathway. While venous sinus stenting has emerged as a promising treatment for idiopathic intracranial hypertension, its efficiency on idiopathic CSF leaks has not been very well addressed in the literature so far. The purpose of this study was to report the results of transverse sinus stenting in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses. From a prospectively collected database, the authors retrospectively collected the clinical and radiological features of the patients with spontaneous CSF leakage who were treated with venous sinus stenting. Five female patients were included in this study. Transverse sinus stenoses were present in all patients, and other radiological signs of idiopathic intracranial hypertension were present in 4 patients. The median transstenotic pressure gradient was 6.5 mm Hg (range 3-9 mm Hg). Venous stenting resulted in the disappearance of the leak in 4 patients with no recurrence and no subsequent meningitis during the follow-up (median 12 months, range 6-63 months). According to the authors' results, venous sinus stenting may result in the disappearance of the leak in many cases of idiopathic CSF rhinorrhea. Larger comparative studies are needed to assess the efficiency and safety of venous stenting as a first-line approach in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

MR findings suggestive of idiopathic intracranial hypertension in 117 patients with spontaneous cerebrospinal fluid rhinorrhea.

The purpose of this study is to document the prevalence of MR findings suggestive of idiopathic intracranial hypertension (IIH) in patients undergoing endoscopic repair of spontaneous CSF rhinorrhea (SCSFR). In a retrospective study, MR images of 117 consecutive patients who had undergone endoscopic repair of SCSFR were evaluated for features suggestive of IIH (empty sella, widened optic nerve sheath, tortuous optic nerve, flattened posterior globe, and enlarged Meckel's cave). Pituitary height was used to diagnose partial and complete empty sella. MR images were independently evaluated by two of the authors without knowledge of the clinical findings. Consensus method was used to resolve differences between the two evaluators. Empty or partially empty sella was diagnosed in the MR of 105 (89.7%) patients. In 38/105 (36.2%) patients with empty/partial empty sella, no additional MR findings were present. In 43/105 (41%) patients, one or more of the MR features with high specificity for diagnosis of IIH (flattened posterior globe and enlarged Meckel's cave) were seen. In the other 24 (22.9%) additional MR findings, less specific for IIH (widened optic nerve sheath, tortuous optic nerve) were noted. Papilledema was seen in 11 of 60 (18.3%) patients who underwent funduscopic examination. All patients with papilledema had empty/partial empty sella, and 9/11 (81.8%) had an additional MR finding suggestive of IIH. The majority of patients with SCSFR have MR imaging features of IIH. These imaging features should be a major component of previously published modified diagnostic criteria for IIH in patients with SCSFR.

The Key Role of Packing Technique for Successful Endoscopic Repair of CSF Rhinorhea

Abstract Background: Spontaneous CSF leaks are rare, their diag-nosis is often delayed, and they can precipitate meningitis. Craniotomy and intracranial approach is the historical gold standard repair for these leaks [1]. Anendonasal endoscopic approach offers potentially less invasiveness and lower surgical morbidity than a traditional craniotomy but must yield the same surgical success [2]. Recurrence of these leaks is not uncommon. One of the most important factors of this recur-rence is inadequate support of the flaps or grafts or loose cooptation of raw surfaces which may be unable to resist the normotensive CSF leak. Maintaining adequate continuous low grade pressure intraoperativelyand two weeks post-operatively may optimize the best chance for raw areas to heal properly with minimal recurrence. Aim of Study: The aim of this study is to identify and discuss the pivotal role of intraoperative packing and its technique to obtain a successful repair of CSF rhinorrhea. Patients and Methods: A prospective randomized study conducted on 14 patients suffering spontaneous CSF rhinor-rhea, from March 2018 to April 2020 in Hearing and Speech Institute. The 14 patients have been divided into two equal groups 7 patients each, group A and group B. In group A, traditional nasal packing was done, whoever, in group B, the special packing was done in the form two packs, the first pack over the grafted area was two layered composed of 1mm thickness silasticsheet over the graft and raw area and a piece of Merocel 1 by 1.5cmms supporting the silastic sheet. The second pack was placed in the nasal cavity. The first pack has been changed weekly to two or three weeks then removed finally. Results: All patients were doing well throughout the follow-up period. In group A, there was recurrence in fourpa-tients, two after six months and two after one year. In group B there was one recurrence after one year of follow-up.Abstract Background: Spontaneous CSF leaks are rare, their diag-nosis is often delayed, and they can precipitate meningitis. Craniotomy and intracranial approach is the historical gold standard repair for these leaks [1]. Anendonasal endoscopic approach offers potentially less invasiveness and lower surgical morbidity than a traditional craniotomy but must yield the same surgical success [2]. Recurrence of these leaks is not uncommon. One of the most important factors of this recur-rence is inadequate support of the flaps or grafts or loose cooptation of raw surfaces which may be unable to resist the normotensive CSF leak. Maintaining adequate continuous low grade pressure intraoperativelyand two weeks post-operatively may optimize the best chance for raw areas to heal properly with minimal recurrence. Aim of Study: The aim of this study is to identify and discuss the pivotal role of intraoperative packing and its technique to obtain a successful repair of CSF rhinorrhea. Patients and Methods: A prospective randomized study conducted on 14 patients suffering spontaneous CSF rhinor-rhea, from March 2018 to April 2020 in Hearing and Speech Institute. The 14 patients have been divided into two equal groups 7 patients each, group A and group B. In group A, traditional nasal packing was done, whoever, in group B, the special packing was done in the form two packs, the first pack over the grafted area was two layered composed of 1mm thickness silasticsheet over the graft and raw area and a piece of Merocel 1 by 1.5cmms supporting the silastic sheet. The second pack was placed in the nasal cavity. The first pack has been changed weekly to two or three weeks then removed finally. Results: All patients were doing well throughout the follow-up period. In group A, there was recurrence in fourpa-tients, two after six months and two after one year. In group B there was one recurrence after one year of follow-up.

Meningocele in the olfactory area in spontaneous CSF rhinorrhea

Introduction: Spontaneous leakage of cerebrospinal fluid from the nasal cavity due to a defect in the anterior, middle and posterior skull base is a condition associated with both difficult clinical diagnosis and challenges in preoperative localization and treatment. Material and methods: For a period of 19 years in the Clinic of Ear, Nose and Throat at the University Hospital “St. George” were diagnosed 11 cases of spontaneous rhinorrhea with the presence of meningocele in the area of the olfactory cleft Results: In 8 of the clinical cases, we administered intrathecal fluorescein 10% due to the inconclusive data from HRCT and MRI / Cisternography for bone and dural defect in the base area in a positive beta 2 transferrin test. We find that the olfactory cleft is common localization in spontaneous CSF rhinorrhea. Conclusion: The elective choice of diagnostic method with aimed examination for defectarachnoid dilatation in the area of lamina cribrosa, meningocele in the area of the olfactory cleft and those in the sphenoid sinus significantly improves the quality of surgical treatment (preservation of the olfactory area on one side, minimizing orbital and additional dural defects). The discussion in multidisciplinary teams provides significant opportunities for accurate and timely diagnosis of this type of “hidden” defects. ------------------------------------------------------------------------------ Въведение: Спонтанното изтичане на ликвор от носната кухина вследствие на дефект в областта на предна, средна и задна база на черепа е състояние, свързано както със затруднено клинично диагностициране, така и с предизвикателства в предоперативното локализиране и лечение. Материал и методи: За период от 19 години в Клиниката по уши нос и гърло в УМБАЛ „Свети Георги“ са диагностицирани 11 случаи на спонтанна риноликворея с наличие на менингоцеле в областта на олфакторната цепка. Резултати: При 8 от клиничните случаи сме приложили интратекално флуоресцеин 10% поради неубедителните данни от HRCT и МРТ/ цистернография за костен и дурален дефект в областта на базата при позитивен бета 2 трансферинов тест. Установяваме, че олфакторната зона е най-честата локализация при спонтанна риноликворея. Заключение: Елективният избор на метод за диагностика с насочено търсене на дефект-арахноидна дилатация в областта на ламина криброза, менингоцеле в областта на олфактоната цепка, както и такива в сфеноидалния синус значително подобрява качеството в оперативното лечение (запазване на олфакторна зона от едната страна, минимизиране орбитални и допълнителни дурални дефекти). Съвместното дискутиране в мултидисциплинарни екипи дава значителни възможности за акуратната и навременна диагностика на този тип „скрити“ дефекти.

Retrospective Analysis of Transnasal Endoscopic CSF Rhinorrhea Repair in a Tertiary Care Centre.

To analyse the outcome of transnasal endoscopic repair of CSF Rhinorrhea in a tertiary care centre. This is a retrospective study conducted on 81 patients who underwent CSF Rhinorrhea repair in a tertiary care hospital for a period of 11years. Following confirmation of diagnosis using bio-chemical and radiological investigations, all patients underwent transnasal endoscopic repair of CSF Rhinorrhea using a multilayer graft. Patients were followed up for 6months. The most common etiology in our study was spontaneous CSF rhinorrhea (60.49%) and subjects with BMI > 25.5kg/m2 were more prone to it. Cribriform plate was found to be the most frequent site of leak in our study (58.02%), followed by fovea ethmoidalis (12.35%). Overall success rate was 96.30%. Transnasal endoscopic approach for cerebrospinal fluid rhinorrhea repair shows good success rate and also offers the advantages of better visualization and identification of site of leak, less complications, rapid postoperative recovery, and low recurrence rate. Transnasal endoscopic CSF Rhinorrhea repair has shown good results in terms of low recurrence rates and high patient satisfaction among other advantages. Hence this approach should be commonly used for CSF rhinorrhea repair by surgeons.

Endoscopic Repair of Spontaneous CSF Rhinorrhoea: Results from 21 Cases

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

Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea.

Spontaneous CSF leaks are rare, their diagnosis is often delayed, and they can precipitate meningitis. Craniotomy is the historical "gold standard" repair for these leaks. An endonasal endoscopic approach (EEA) offers potentially less invasiveness and lower surgical morbidity than a traditional craniotomy but must yield the same surgical success. A paucity of data exists studying EEA as the primary management for spontaneous CSF leaks. The authors retrospectively reviewed patients undergoing spontaneous CSF rhinorrhea repair at their institution from July 2010 to August 2018. Standardized management includes EEA as first-line treatment, and lumbar puncture (LP) performed 24-48 hours postoperatively. If opening pressure on LP is elevated, CSF diversion or acetazolamide therapy is used as needed. Perioperative lumbar drains are not used. Of 46 patients identified, the most common CSF rhinorrhea etiology was encephalocele (28/46, 60.9%), and the most common location was cribriform/ethmoid (26/46, 56.5%). Forty-three patients underwent EEA alone, and 3 underwent a simultaneous EEA/craniotomy. The most common repair strategy was nasoseptal or other pedicled flaps (18/46, 39.1%). Postoperatively, 15 patients (32.6%) received CSF diversion due to elevated ICP, with BMI > 40 kg/m2 being a significant risk factor (odds ratio 4.35, p = 0.033) for postrepair shunt placement. Twelve patients received acetazolamide therapy for treatment of mildly elevated pressures. The average opening pressure of the shunted group was 36 cm H2O and the average for the acetazolamide-only group was 26 cm H2O. Two patients underwent CSF leak repair revision, one because of progressive fungal sinusitis and the other because of recurrent CSF leak. The mean follow-up duration was 15 months. The paradigm of EEA repair of spontaneous CSF rhinorrhea with postoperative LP to identify undiagnosed idiopathic intracranial hypertension appears to be safe and effective. In the authors' cohort, morbid obesity was statistically associated with the need for postoperative CSF diversion. This has implications for future surgical treatment as obesity levels continue to rise worldwide.

The Management of Spontaneous Cerebrospinal Fluid Rhinorrhea in Patients at Risk for Increased Intracranial Tension

Introduction: The exact pathophysiology of spontaneous CSF rhinorrhea is not always understood in some patients. Idiopathic intracranial hypertension (IIH) is now recognized as one of the causes of spontaneous CSF leak in the neurosurgical and ENT literature. Our aim was to set a management protocol for such cases according to the same setting intracranial tension (ICT). Methods: We prospectively managed patients with spontaneous CSF rhinorrhea who were admitted to our hospital between 1st of January 2014 and 31st of December 2017 with a prespecified treatment algorithm. Patients with a history of previous cranial or nasal surgery, trauma, skull base congenital malformations were excluded from the study. The patient’s demographics, clinical data, comorbidities, body mass index (BMI), first time or recurrent leakage and duration of the leak were collected. Results: 41 patients, 35 females and 6 males, presented with spontaneous CSF rhinorrhea with a mean BMI of 38 ± 4.16 Kg/m2. The mean pre-operative ICT manometry was 17.2 ± 5.9 cmH2O (range, 10 - 26 cmH2O). 43.9% of the patients were found to have an increased ICT (≥20 cmH2O) and underwent a permanent CSF diversion at the same setting of the endoscopic repair. None of the patients had a recurrence during the follow-up period. Conclusion: The prespecified treatment algorithm with measuring the ICT at the same setting of the endoscopic repair has a better result for control of spontaneous CSF rhinorrhea. This has led to no recurrence and decreased hospital stay.

Approach to Management of Cerebrospinal Fluid Rhinorrhea: Institutional Based Protocol.

The role of otolaryngologist in the management of CSF rhinorrhea is expanding. It is prudent to evaluate all cases of CSF leak, understand the etiological causes and formalize a working approach to management of such cases to yield better outcome. A retrospective descriptive study of 39 cases of proven CSF rhinorrhea treated at a tertiary care center between January 2014 to August 2019. The data retrieved were analyzed for age, gender, weight, etiology, recurrence of the disease, history of meningitis, nasal or neurosurgical intervention in past, imaging inform of CT and MR cisternography as and when required. This was aimed at understanding the various etiological types of CSF rhinorrhea and work out a management approach. The patients with skullbase tumors who presented with CSF Rhinorrhea were excluded from the study sample. There were 18 cases of spontaneous CSF rhinorrhea and 20 cases of traumatic CSF rhinorrhea. The mean BMI of spontaneous gp was 32.9 ± 2.46kg/m2 while in traumatic group was 25.7 ± 2.94kg/m2 and difference was statistically significant. None of the spontaneous CSF rhinorrhea cases showed features of raised ICP preoperatively either clinically or on imaging except empty sella in 14 of 18 cases. 6 of 18 cases of spontaneous category while 01 of 20 cases in traumatic had recurrence and the recurrence rate was significantly (p < 0.05) higher in spontaneous group. In traumatic group 7 were iatrogenic, 8 were occult traumatic and rest were acute traumatic. 4 of traumatic and 1 spontaneous group had history of meningitis and the incidence was 12.8% in our study group. Early identification and localization of CSF fistula is necessary to reduce morbidity and mortality associated with it. Risk of meningitis is high in CSF rhinorrhea especially in traumatic group. The etiology of CSF rhinorrhea has a bearing on the management and spontaneous CSF rhinorrhea has higher rate of recurrence.

075 A case of spontaneous CSF rhinorrhea in a patient with marfan syndrome

IntroductionSpontaneous cerebrospinal fluid leak is uncommon condition and frequently associated with hereditary disorders of connective tissues. Nasal CSF leakage is extremely rare.1Methods and resultsWe present the case of a 40-year-old woman presented to hospital for few days history of postural headache associated with clear intermittent discharge from right nostril without any signs of meningism. There was no history of trauma. She has a background history of Marfan syndrome with associated complications of ASD repair at age 2, mechanical Aortic and Mitral valve replacement, aortic root repair, previous ST elevation MI with LV dysfunction, automated implantable cardioverter-defibrillator in situ, atrial fibrillation, and Hashimoto’s thyroiditis. Her regular medications are warfarin, bisoprolol and thyroxine. The clear nasal discharge was positive for β-2 transferrin confirming cerebrospinal fluid. Her CT Brain did not reveal any clear site of CSF leak. She had a flexible nasendoscopy which showed normal nasal passageway, no defect in nasal mucosa and no active CSF leakage. She was managed conservatively with strict bed rest and advised to minimise strenuous activity and heavy lifting.ConclusionSpontaneous cerebrospinal fluid leak is uncommon condition and frequently associated with hereditary disorders of connective tissues. Nasal CSF leakage is extremely rare.1 Testing β-2 transferrin has high sensitivity and specificity.2Initial treatment may include bed rest, oral or intravenous hydration, oral caffeine or corticosteroids.3 4 If conservative therapy fails, surgical repair with nasal endoscopic approach is recommended.2 5ReferencesOmmaya A, Di Chiro G, Baldwin M, Pennybacker J. Non-traumatic cerebrospinal fluid rhinorrhoea. Journal of Neurology, Neurosurgery &amp; Psychiatry 1968;31(3):214-–225.Wang E, Vandergrift W, Schlosser R. Spontaneous CSF Leaks. Otolaryngologic Clinics of North America 2011;44(4):845–856.Milledge J, Ades L, Cooper M, Jaumees A, Onikul E. Severe spontaneous intracranial hypotension and Marfan syndrome in an adolescent. Journal of Paediatrics and Child Health 2005;41(1–2):68–71.Placantonakis D, Bassani L, Graffeo C, Behrooz N, Tyagi V, Wilson T, et al. Noninvasive diagnosis and management of spontaneous intracranial hypotension in patients with marfan syndrome: Case Report and Review of the Literature. Surgical Neurology International 2014;5(1):8.Spontaneous cerebrospinal fluid rhinorrhea. Medicine 2018;97(7):e9954.

Outcome of Endoscopic Cerebrospinal Fluid Rhinorrhoea Repair: An Institutional Study.

Cerebrospinal fluid Rhinorrhoea is caused by an abnormal open communication between the subarachnoid space and the nasal cavity. The most common anatomic sites of such abnormal communication are found in the anterior skull base, namely, ethmoid roof, olfactory groove, roof of the sphenoid sinus and the posterior wall of the frontal sinus. It can be classified into traumatic or spontaneous. Spontaneous leaks are associated with highest recurrence rates following surgical repair. The repair of CSF Rhinorrhoea has rapidly evolved over the past 30years. Prior to the advent of the endoscopic approach, craniotomy was used for repairs which carried a variable success rate and morbidity. The purpose of our study was to ascertain the outcome after Transnasal Endoscopic Repair of spontaneous CSF leaks. This was a prospective study conducted at the Department of ENT at Safdarjung Hospital, New Delhi between January 2015 and June 2016. The study comprised of eleven patients who presented with the complaint of watery nasal discharge and were diagnosed to have spontaneous CSF Rhinorrhoea. Proper clinical examination, nasal endoscopy and biochemical and cytological analysis of nasal secretions of the patient was done. High Resolution Computed Tomography and MRI scans of the nose and paranasal sinuses were done to identify precise location of CSF leak and the size of fistula. CT cisternography was done wherever required. Fistula was repaired via Transnasal endoscopic approach in a multi layered underlay fashion. Out of all eleven patients with spontaneous CSF leaks, most common site of leak was from left cribriform area. Four patients (36.36%) were found to have meningoencephalocele. No associated intracranial lesion was found and all patients did not have any benign intracranial hypertension. Our success rate of endoscopic repair on first attempt was 100% with recurrence in 1 patient after 4months of repair. Endoscopic repair of CSF rhinorrhoea is safe and effective, with a very low complication rate. It has almost completely replaced the older open techniques. Accurate localization of leak site followed by multilayered closure of dural defect appear to be essential for successful endoscopic repair.

Spontaneous Medial Cribriform CSF Leak: Endoscopic Surgical Repair with Free Mucosal Graft-Our Experience.

Cribriform plate is the commonest site of spontaneous CSF leak, the fragility of the plate and juxtaposition of arachnoid's investment to the bone, where the olfactory nerve pierces the skull made this area, a vulnerable site for CSF leak. Transnasal endoscopic approach has gained popularity for CSF leak repair over the years. To describe the 5year experience of spontaneous medial cribriform CSF leak repair with free mucosal graft in a tertiary medical centre. All patients who underwent transnasal endoscopic repair with free mucosal graft for spontaneous medial cribriform CSF leak in our institution between 2011 and 2016 were reviewed. Twelve patients were identified, all were women with a mean age of 44.5years. The defect was localised by preoperative computed tomography scans with 1mm cuts and MR cisternography. Via medial approach, the mucosa surrounding the entire defect was denuded and the defect was closed with free mucosal graft harvested either from the middle turbinate or from the nasal septum and middle turbinate was finally sutured with septum to stabilise the repair. The overall success rate was 100% with the first attempt with no recurrence or postoperative complications. Follow up ranged from 1 to 5years. The endoscopic transnasal technique with free mucosal graft for the repair of spontaneous medial cribriform CSF rhinorrhoea is associated with a very high success rate and it should be considered for majority of cases.

Vascularized middle turbinate mucoperiosteal flap in skull base defects: follow-up analysis of 20 cases

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Vascularized flaps are preferred in repair of skull base defects since they provide quality tissue volume and allow rapid healing. Though nasoseptal flap is the gold standard it may not be available always and has its own share of pitfalls; this makes the middle turbinate flap a viable alternative. This descriptive study was designed to analyze the efficacy of middle turbinate flap in endoscopic closure of skull base defects and to define indications and limitations of the flap.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 20 patients who underwent endoscopic closure of small and medium sized skull base defects using middle turbinate mucoperiosteal flap were analyzed and followed up. Etiology, presentation, site and co-morbidities associated with such defects were studied. Effectiveness of closure was analyzed by the ability to cover fully, graft uptake and complications. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Successful flap take up was noted in all 20 cases (100%) on long term follow up; transient cerebrospinal fluid leak was observed in 1case (5%) during the immediate post-operative period which subsided fully. Spontaneous CSF rhinorrhea (n=11 [55%]) was the most common indication for closure and unilateral watery rhinorrhea was the commonest presentation (n=13 [65%]). Benign intracranial hypertension was found to have significant association with cerebrospinal fluid rhinorrhea. Most common site of leak was the medial lamella of cribriform plate (n=11 [55%]).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Middle turbinate flap is an effective alternative to nasoseptal flap for small and medium sized anterior skull base defects; efficacy in larger defects and posterior sellar defects cannot be substantiated. &lt;/p&gt;

A 17-years-old girl presenting with spontaneous cerebrospinal fluid rhinorrhea diagnosed as aqueductal stenosis: A case report

A 17-year-old girl presented with chronic headache and spontaneous CSF rhinorrhea. She had no history of head trauma. MRI of her brain showed aqueductal stenosis associated with triventriculomegaly with partially empty sella. Following insertion of ventriculoperitoneal shunt, her headache and CSF rhinorrhea completely recovered. Though very uncommon but aqueductal stenosis should be kept as a differential diagnosis for etiology of chronic CSF rhinorrhea.

Variations in Lateral Sphenoid Sinus Wall Defects

Objective The article aims to present different forms of lateral sphenoid sinus wall defects. Study Design Case series and literature review. Methods A comparison between two patients who presented with spontaneous CSF rhinorrhea, defects in the lateral wall of the sphenoid sinus, and meningeal contents in the sphenoid sinus based on MRI is discussed. Both patients were operated endoscopically, through a trans-nasal-ethmoid-pterygoid approach. Results In the first patient, a meningoencephalocele, protruding through a defect in the lateral sphenoid sinus wall and pterygoid base, occupied the inferior part of the sphenoid sinus. In the second patient, there were no exposed meningeal contents inside the sphenoid sinus. Instead, the lateral sphenoid sinus wall was thin and bulging medially into the inferior part of the sinus, with the dura and temporal lobe covered with thin bony cap. Conclusion Complete dehiscence of the lateral wall of the sphenoid sinus results in exposed meningeal contents inside the sphenoid sinus. In partial dehiscence, the thin and weakened lateral wall of the sphenoid sinus yields to the pressure of the temporal lobe and bulges into the sphenoid sinus cavity. There are no other descriptions of partially dehiscent lateral sphenoid sinus walls in the literature.

Spontaneous CSF Rhinorrhea as Clinical Symptom of an Idiopathic Temporal Encephalocele in a 64 Year Old Man

A rare case of idiopathic temporomesial encephalocele in a 64 years old female is presented. The clinical symptoms of this adult patient were spontaneous rhinorrhea and headaches. A temporomesial encephalocele could be diagnosed and the cele was removed surgically in two operative procedures. In case of clinical symptoms like rhinorrhea a surgical removal of the encephalocele is recommended to prevent infections like meningitis.

A Unified Management for Spontaneous CSF Leak

Background: Spontaneous CSF leak represents less frequent cause of CSF leak, but cases are more difficult to control, with the highest failure rate and recurrence despite adequate repair. The problems in these cases might be related to an underlying undiagnosed associated intracranial hyper-tension. Recognition and long-term treatment of elevated ICP is therefore critical to the successful management of these patients. Objective: To evaluate the CSF pressure in cases of spontaneous CSF rhinorrhea and to describe our same setting combined protocol to the repair of the leak, measurement and management of CSF pressure. Patients and Methods: All patients presenting to Ain Shams University Hospitals, Cairo, Egypt, with spontaneous CSF leak were included prospectively in the study. Clinical and radiologic data were collected to suspect elevated intracranial pressure. After CSF repair, CSF pressure was measured and if found to be more than 20 cmH2O, a lumboperitoneal shunt was used. Results: Twenty-seven cases, 23 women and 4 men, presented with spontaneous CSF leak. 23 patients had BMI above 30. All patients had empty sella syndrome (100%), and a meningoencephalocele was found in 13 cases (48%). CSF pressure ranged from 5 to 39 cmH2O (mean = 28.7). A pressure above 21 cmH2O was found in19 patients (70%) and subsequently had lumboperitoneal shunt in the same setting. No recurrence occurred in this subset of patients with 6 - 60 months follow-up period. Conclusion: A selective and specific same setting protocol can result in a better diagnosis and control of the accompanying elevated ICP in cases of spontaneous CSF leak. It avoids a second operative intervention, and shortens the hospital stay, with an increase in the success rate. In the same time, the smaller number of patients with normal ICP can avoid further drainage.