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Hiremath SB, Gautam AA, Sasindran V, Therakathu J, Benjamin G. Cerebrospinal fluid rhinorrhea and otorrhea: A multimodality imaging approach. Diagn Interv Imaging 2018; 100:3-15. [PMID: 29910174 DOI: 10.1016/j.diii.2018.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/07/2018] [Accepted: 05/16/2018] [Indexed: 12/16/2022]
Abstract
Cerebrospinal fluid (CSF) leaks are extracranial egress of CSF into the adjacent paranasal sinus or tympanomastoid cavity due to an osteodural defect involving skull base. It can be due to a multitude of causes including accidental or iatrogenic trauma, congenital malformations and spontaneous leaks. Accurate localization of the site of the leak, underlying causes and appropriate therapy is necessary to avoid associated complications. In this paper relevant anatomy, clinical diagnosis, imaging modalities and associated findings are discussed along with a brief mention about management.
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Affiliation(s)
- S B Hiremath
- Department of Radiodiagnosis, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, 689101 Kerala, India
| | - A A Gautam
- Department of Radiodiagnosis, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, 689101 Kerala, India.
| | - V Sasindran
- Department of Otolaryngorhinology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, 689101 Kerala, India
| | - J Therakathu
- Department of Radiodiagnosis, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, 689101 Kerala, India
| | - G Benjamin
- Department of Radiodiagnosis, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, 689101 Kerala, India
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Recurrent CSF Rhinorrhea Misdiagnosed as Chronic Allergic Rhinitis with Subsequent Development of Bacterial Meningitis. Case Rep Med 2017; 2017:9012579. [PMID: 28819362 PMCID: PMC5551538 DOI: 10.1155/2017/9012579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/02/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cerebrospinal fluid (CSF) rhinorrhea results from an abnormal communication of the dura mater to the nasal mucosa. The majority of cases of CSF rhinorrhea are the result of trauma or surgery involving the skull base. Spontaneous CSF rhinorrhea is a rare clinical entity with increased risk of ascending infection. Delay in diagnosis places the patient at risk of developing meningitis. CASE PRESENTATION A 36-year-old African American female with significant medical history of obesity and hypertension presented to the emergency department with headache, altered level of consciousness, fever, and neck stiffness. Previously, the patient was diagnosed with chronic allergic sinusitis by multiple providers. Physical exam findings and laboratory tests were consistent with bacterial meningitis. The patient was admitted and started on appropriate antibiotic therapy. The patient continued to complain of persistent unilateral clear nasal drainage. The initial report from the computerized tomography scan of the sinuses indicated findings consistent with chronic sinusitis. Magnetic resonance imaging of the orbits revealed findings consistent with CSF rhinorrhea. Otolaryngology was consulted for surgical intervention. CONCLUSION Suspected CSF rhinorrhea should prompt immediate biochemical and radiologic evaluation and surgical consultation. CSF rhinorrhea places patients at risk of developing bacterial meningitis.
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Fraser S, Gardner PA, Koutourousiou M, Kubik M, Fernandez-Miranda JC, Snyderman CH, Wang EW. Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurosurg 2017; 128:1066-1071. [PMID: 28598276 DOI: 10.3171/2016.12.jns1694] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim in this paper was to determine risk factors for the development of a postoperative CSF leak after an endoscopic endonasal approach (EEA) for resection of skull base tumors. METHODS A retrospective review of patients who underwent EEA for the resection of intradural pathology between January 1997 and June 2012 was performed. Basic demographic data were collected, along with patient body mass index (BMI), tumor pathology, reconstruction technique, lumbar drainage, and outcomes. RESULTS Of the 615 patients studied, 103 developed a postoperative CSF leak (16.7%). Sex and perioperative lumbar drainage did not affect CSF leakage rates. Posterior fossa tumors had the highest rate of CSF leakage (32.6%), followed by anterior skull base lesions (21.0%) and sellar/suprasellar lesions (9.9%) (p < 0.0001). There was a higher leakage rate for overweight and obese patients (BMI > 25 kg/m2) than for those with a healthy-weight BMI (18.7% vs 11.5%; p = 0.04). Patients in whom a pedicled vascularized flap was used for reconstruction had a lower leakage rate than those in whom a free graft was used (13.5% vs 27.8%; p = 0.0015). In patients with a BMI > 25 kg/m2, the use of a pedicled flap reduced the rate of CSF leakage from 29.5% to 15.0% (p = 0.001); in patients of normal weight, this reduction did not reach statistical significance (21.9% [pedicled flap] vs 9.2% [free graft]; p = 0.09). CONCLUSIONS Preoperative BMI > 25 kg/m2 and tumor location in the posterior fossa were associated with higher rates of postoperative CSF leak. Use of a pedicled vascularized flap may be associated with reduced risk of a CSF leak, particularly in overweight patients.
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Affiliation(s)
| | - Paul A Gardner
- 2Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | | | | | - Carl H Snyderman
- Departments of1Otolaryngology and.,2Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Stevens SM, Rizk HG, Golnik K, Andaluz N, Samy RN, Meyer TA, Lambert PR. Idiopathic intracranial hypertension: Contemporary review and implications for the otolaryngologist. Laryngoscope 2017; 128:248-256. [PMID: 28349571 DOI: 10.1002/lary.26581] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES 1) Review controversies pertaining to the pathophysiology, diagnosis, and treatment of idiopathic intracranial hypertension. 2) Discuss the evolving role of otolaryngologists in managing this disease and related disorders. DATA SOURCES Primary literature review, Centers for Disease Control and Prevention website, International Classification of Headache Disorders, Second Edition. METHODS A comprehensive review of the primary literature was performed from 1990 to 2016 utilizing keywords idiopathic intracranial hypertension, pseudotumor cerebri, benign intracranial hypertension, spontaneous cerebrospinal fluid leak, and encephalocele. Articles were included at the discretion of the authors based on novel and/or historical contributions to the literature. RESULTS The incidence of idiopathic intracranial hypertension is increasing along with the obesity epidemic. Undiagnosed patients may present to otolaryngologists with pulsatile tinnitus, dizziness, sleep apnea, and spontaneous cerebrospinal fluid leaks. Although diagnosis is predicated upon imaging findings and lumbar puncture, radiographic signs including empty sella, optic nerve dilation, and globe flattening may suggest the diagnosis. The most effective intervention is weight loss combined with acetazolamide. Surgery is reserved for severe or refractory symptoms and can be highly morbid. Otolaryngologists are increasingly responsible for managing a number of secondary disorders including cerebrospinal fluid rhinorrhea and otorrhea. Failure to manage intracranial hypertension may lead to adverse surgical outcomes. CONCLUSIONS The knowledge base for idiopathic intracranial hypertension has greatly expanded over the past 25 years. This disease is associated with a number of conditions directly relevant to otolaryngologists. A keen understanding of this disorder and its management may optimize outcomes in a growing number of patients. Laryngoscope, 128:248-256, 2018.
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Affiliation(s)
- Shawn M Stevens
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Karl Golnik
- Department of Ophthalmology, Cincinnati Eye Institute, Cincinnati, Ohio, U.S.A
| | - Norberto Andaluz
- Division of Skull Base Surgery, Mayfield Brain & Spine, Cincinnati, Ohio, U.S.A
| | - Ravi N Samy
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine and Neurosensory Disorders Center at University of Cincinnati Neuroscience Institute, Cincinnati, Ohio, U.S.A
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Paul R Lambert
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Abstract
As the obesity epidemic grows in the United States, rhinorrhea and otorrhea from spontaneous cerebrospinal fluid (CSF) leaks secondary to untreated idiopathic intracranial hypertension are increasing in prevalence. CSF rhinorrhea and otorrhea should also be carefully evaluated in posttraumatic and postsurgical settings, because untreated CSF leaks often have serious consequences. The work-up, diagnosis, and characterization of a CSF leak can be complex, often requiring a multimodality approach to optimize surgical planning. This article reviews the causes of CSF leaks, describes the methodology used to work up a suspected leak, and discusses the challenges of making an accurate diagnosis.
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Affiliation(s)
- Mahati Reddy
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University Hospital, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA
| | - Kristen Baugnon
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Emory University Hospital, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA.
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Darouassi Y, Mliha Touati M, Chihani M, Akhaddar A, Ammar H, Bouaity B. Spontaneous cerebrospinal fluid leak of the sphenoid sinus mimicking allergic rhinitis, and managed successfully by a ventriculoperitoneal shunt: a case report. J Med Case Rep 2016; 10:308. [PMID: 27809892 PMCID: PMC5094058 DOI: 10.1186/s13256-016-1107-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spontaneous cerebrospinal fluid leaks are rare but may lead to confusion with other diseases in patients without history of trauma. We report a rare case unusual for two reasons. First, our patient was put under antiallergic medication for months before the diagnosis of spontaneous cerebrospinal fluid leak of the sphenoid sinus. Second, our patient was managed successfully by a ventriculoperitoneal shunt. CASE PRESENTATION Our patient was a nonobese 49-year-old Arab man without history of trauma or surgery who presented with rhinorrhea. He was given allergic rhinitis medication for 4 months without improvement. After the onset of headache leading to the suspicion of paranasal sinusitis, a computed tomography scan discovered an osteodural defect in the sphenoid sinus roof and a magnetic resonance imaging scan showed an aspect of empty sella with an arachnoidocele. An eye fundus examination found papilledema suggesting the diagnosis of idiopathic intracranial hypertension. We performed a ventriculoperitoneal shunt without repair of the osteodural defect. Because of the favorable evolution, we decided to postpone surgery. CONCLUSIONS Spontaneous cerebrospinal fluid leak should be considered even in nonobese male patients without history of trauma. Our observation adds to other case reports suggesting the decrease of cerebrospinal fluid pressure alone as an option for the treatment of spontaneous cerebrospinal fluid leaks. Additional studies are necessary to clarify the indications.
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Affiliation(s)
| | | | - Mehdi Chihani
- ENT Department, Military Hospital Avicenna, Marrakech, Morocco
| | - Ali Akhaddar
- Neurosurgery Department, Military Hospital Avicenna, Marrakech, Morocco
| | - Haddou Ammar
- ENT Department, Military Hospital Avicenna, Marrakech, Morocco
| | - Brahim Bouaity
- ENT Department, Military Hospital Avicenna, Marrakech, Morocco
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Karnezis TT, Baker AB, Soler ZM, Wise SK, Rereddy SK, Patel ZM, Oyesiku NM, DelGaudio JM, Hadjipanayis CG, Woodworth BA, Riley KO, Lee J, Cusimano MD, Govindaraj S, Psaltis A, Wormald PJ, Santoreneos S, Sindwani R, Trosman S, Stokken JK, Woodard TD, Recinos PF, Vandergrift WA, Schlosser RJ. Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery. Int Forum Allergy Rhinol 2016; 6:1117-1125. [DOI: 10.1002/alr.21783] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 02/02/2016] [Accepted: 03/08/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Tom T. Karnezis
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Andrew B. Baker
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Zachary M. Soler
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Sarah K. Wise
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Shruthi K. Rereddy
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | - Zara M. Patel
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | | | - John M. DelGaudio
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta GA
| | | | - Bradford A. Woodworth
- Division of Otolaryngology-Head & Neck Surgery; University of Alabama at Birmingham; Birmingham AL
| | - Kristen O. Riley
- Department of Neurosurgery; University of Alabama at Birmingham; Birmingham AL
| | - John Lee
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto; St. Michael's Hospital; Toronto ON Canada
| | - Michael D. Cusimano
- Department of Neurosurgery, St. Michael's Hospital; University of Toronto; Toronto ON Canada
| | - Satish Govindaraj
- Department of Otolaryngology-Head & Neck Surgery; Mount Sinai Hospital; New York NY
| | - Alkis Psaltis
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide Australia
| | - Peter John Wormald
- Department of Otolaryngology-Head & Neck Surgery; Royal Adelaide Hospital; Adelaide Australia
| | - Steve Santoreneos
- Department of Neurosurgery; Royal Adelaide Hospital; Adelaide Australia
| | - Raj Sindwani
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | - Samuel Trosman
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | - Janalee K. Stokken
- Department of Otolaryngology-Head & Neck Surgery; Mayo Clinic; Rochester MN
| | - Troy D. Woodard
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | - Pablo F. Recinos
- Section of Rhinology, Head and Neck Institute; Cleveland Clinic; Cleveland OH
| | | | - Rodney J. Schlosser
- Department of Otolaryngology-Head & Neck Surgery; Medical University of South Carolina; Charleston SC
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Horcajadas Almansa A, Román Cutillas A, Jorques Infante A, Ruiz Gómez J, Busquier H. [Idiopathic intracranial hypertension and spontaneous cerebrospinal fluid fistula. Usefulness of intracranial pressure monitoring]. Neurocirugia (Astur) 2016; 28:93-96. [PMID: 27445081 DOI: 10.1016/j.neucir.2016.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/08/2016] [Accepted: 06/19/2016] [Indexed: 10/21/2022]
Abstract
Spontaneous cerebrospinal fluid (CSF) fistulas are rather common in daily practice. The aim of the surgical treatment is closure of the leak, but recurrences are quite frequent. The association between spontaneous CSF fistulas and idiopathic intracranial hypertension (IIH) is not uncommon, and this is probably the cause of the low rate of success of the surgical treatment. Symptoms of IIH associated with spontaneous CSF fistula are atypical, and diagnosis is often missed. Continuous intracranial pressure monitoring is very useful in the diagnosis of chronic IIH and in patients with spontaneous CSF fistula, as it helps in making decisions on the treatment of these patients.
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Affiliation(s)
| | | | | | - José Ruiz Gómez
- Servicio de Otorrinolaringología, Hospital Vithas La Salud, Granada, España
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Kranz PG, Tanpitukpongse TP, Choudhury KR, Amrhein TJ, Gray L. How common is normal cerebrospinal fluid pressure in spontaneous intracranial hypotension? Cephalalgia 2016; 36:1209-1217. [DOI: 10.1177/0333102415623071] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives To determine the proportion of patients with spontaneous intracranial hypotension (SIH) who had a cerebrospinal fluid (CSF) pressure >6 cm H2O and to investigate the clinical and imaging variables associated with CSF pressure ( PCSF) in this condition. Methods We retrospectively reviewed 106 patients with SIH. PCSF was measured by lumbar puncture prior to treatment. Clinical and imaging variables – including demographic data, brain imaging results, symptom duration, and abdominal circumference – were collected. Univariate and multivariate analyses were performed to determine the correlation of these variables with PCSF. Results Sixty-one percent of patients had a PCSF between 6 and 20 cm H2O; only 34% had a PCSF ≤6 cm H2O. The factors associated with increased PCSF included abdominal circumference ( p < 0.001), symptom duration ( p = 0.015), and the absence of brain magnetic resonance imaging findings of SIH ( p = 0.003). A wide variability in PCSF was observed among all patients, which was not completely accounted for by the variables included in the model. Conclusions Normal CSF pressure is common in patients with SIH; the absence of a low opening pressure should not exclude this condition. Body habitus, symptom duration, and brain imaging are correlated with PCSF measurements, but these factors alone do not entirely explain the wide variability in observed pressures in this condition and this suggests the influence of other factors.
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Affiliation(s)
- Peter G Kranz
- Department of Radiology, Duke University Medical Center, USA
| | | | | | | | - Linda Gray
- Department of Radiology, Duke University Medical Center, USA
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Campbell RG, Farquhar D, Zhao N, Chiu AG, Adappa ND, Palmer JN. Cerebrospinal Fluid Rhinorrhea Secondary to Idiopathic Intracranial Hypertension: Long-term Outcomes of Endoscopic Repairs. Am J Rhinol Allergy 2016; 30:294-300. [DOI: 10.2500/ajra.2016.30.4319] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea secondary to idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri or benign intracranial hypertension, has varying success rates, from 25–87%, with minimal morbidity. However, often these series have a relatively short-term follow-up. Given the pathophysiology of IIH, long-term follow-up is necessary to identify true CSF leak recurrence rates. Our investigation aimed to evaluate long-term outcomes in endoscopically repaired CSF leaks. Methods A retrospective chart review of all the patients with CSF rhinorrhea due to IIH who met inclusion criteria between 1996 and 2009. Outcome measures included the following: demographics, intracranial pressure, location of skull base defect, presence of encephalocele and/or meningoencephalocele, surgical repair technique, treatment with acetazolamide, whether a ventriculoperitoneal shunt was inserted, location of recurrence, history of meningitis or previous sinus surgery, and duration of follow-up. Results Thirty-two patients with a total of 44 skull base defects were reviewed over a mean follow-up of 10.2 years. The mean body mass index and intracranial pressure were 36.8 kg/m2 and 27.7 cm H2O, respectively. Seven patients (18%) required revision surgery at the same site or a distant site. We found no statistical significance that identified the recurrence risk in the outcome measurements most likely due to our small failure rate. However, early recurrences were noted to recur at the same repair site, whereas late recurrences were noted to recur at a distant site along the skull base. Conclusion IIH is an increasingly recognized entity treated by otorhinolaryngologists. We present the first long-term IIH CSF leak repair series. Long-term follow-up is necessary because delayed CSF leaks occur in this population.
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Affiliation(s)
- Raewynn G. Campbell
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas Farquhar
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nina Zhao
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander G. Chiu
- Department of Otolaryngology Head and Neck Surgery, The University of Arizona, Tucson, Arizona
| | - Nithin D. Adappa
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N. Palmer
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
PURPOSE OF REVIEW This article aims to review relevant implications of obesity and associated comorbid conditions for the otology and neurotology surgical subspecialties. RECENT FINDINGS Both the incidence and prevalence of obesity are rising worldwide. This condition, along with its many associated comorbidities, can adversely affect the perioperative management of patients undergoing otologic and neurotologic procedures. Preoperative assessment of the cardiopulmonary system and airway are imperative as compromise of either may lead to death. Physiologic changes found in patients with obesity have been shown to predispose to hemodynamic instability, intolerance of hypoxia, bleeding, thrombo-embolism, poor wound healing, and decreased drug clearance. An 'obesity paradox' may exist in which patients who are overweight or obese may have less perioperative morbidity and mortality. Patients who are underweight or morbidly obese seem to have worse surgical outcomes. Obesity has been associated with intracranial hypertension, risk of cerebrospinal fluid (CSF) leak recurrence, and skull base erosion leading to multiple pathologic conditions. These include spontaneous CSF otorrhea, semicircular canal dehiscence syndrome, and sigmoid sinus diverticulum. SUMMARY The obese habitus and physiology significantly affects patients undergoing otologic and neurologic surgeries. A thorough understanding of this condition is paramount to successful outcomes.
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Seltzer J, Babadjouni A, Wrobel BB, Zada G. Resolution of Chronic Aspiration Pneumonitis Following Endoscopic Endonasal Repair of Spontaneous Cerebrospinal Fluid Fistula of the Skull Base. J Neurol Surg Rep 2016; 77:e73-6. [PMID: 27247911 PMCID: PMC4870059 DOI: 10.1055/s-0036-1582238] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Spontaneous cerebrospinal fluid (CSF) rhinorrhea due to a skull base defect requires prompt diagnosis and treatment. Multiple surgical options are available for repairing the fistula, including the two-layer “fascial apposition” method and use of a pedicled nasal-septal flap. A 44-year-old obese woman presented with 4 months of progressive cough, exertional dyspnea, hoarseness, and intermittent fluid drainage from the right nostril. Chest computed tomography (CT) imaging and bronchoscopy showed chronic pneumonitis, which was confirmed by pulmonary wedge resection. CT and magnetic resonance imaging of the skull base, as well as laboratory analysis of the nasal fluid for β2-transferrin, confirmed a skull base defect causing CSF rhinorrhea. During surgery, insertion of a lumbar drain with the intrathecal fluorescein administration was performed, followed by endoscopic endonasal repair using an autologous fascial apposition graft and pedicled nasal-septal flap. Both the CSF leak and the pulmonary complications resolved following the operation with no symptoms at 11-month follow-up. This is the first reported case of spontaneous CSF rhinorrhea complicated by chronic aspiration and pneumonitis. Increased diagnostic complexity due to chronic pulmonary complications resulted in unnecessary interventions and treatment delays. Prompt recognition of spontaneous CSF leaks is essential to prevent potentially harmful complications.
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Affiliation(s)
- Justin Seltzer
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Arash Babadjouni
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Bozena B Wrobel
- Department of Otolaryngology, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
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Stevens SM, Rizk HG, McIlwain WR, Lambert PR, Meyer TA. Association between Lateral Skull Base Thickness and Surgical Outcomes in Spontaneous CSF Otorrhea. Otolaryngol Head Neck Surg 2016; 154:707-14. [PMID: 26908549 DOI: 10.1177/0194599816628528] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/04/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES (1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal fluid (CSF) otorrhea. (2) Augment perioperative counseling of patients with abnormally thin skull bases. STUDY DESIGN Case series with chart review. SETTING Tertiary center. Patients with spontaneous CSF otorrhea have thin skull bases. This is associated with obesity and/or idiopathic intracranial hypertension. The influence of skull base thinning on perioperative outcomes is unknown. SUBJECTS AND METHODS A retrospective review was conducted from 2004 to 2014. Forty-eight cases of spontaneous CSF otorrhea met the inclusion criteria of primary surgery by the senior authors: preoperative dedicated temporal bone computed tomography, absence of other leak etiologies, and follow-up >6 months. Patients were stratified into thin (<0.9 mm) and thick (>0.9 mm) groups based on computed tomography measures of their tegmen. Primary outcomes measures were as follows: postoperative meningitis, recurrent leak, second site leak (contralateral ear/anterior fossa), and permanent shunt placement. Hearing outcomes were not assessed in this study. RESULTS Thirty and 15 patients composed the thin and thick groups, respectively. Both the incidence (P < .0001) and the rate (P = .005) of adverse outcomes were significantly higher in the thin group. Only 2 patients in the thick group experienced an adverse outcome. Eleven patients underwent multiple procedures for spontaneous leaks. The recurrence rate was 14.5%. All but 1 recurrence occurred in the thin group. CONCLUSIONS An abnormally thin tegmen was significantly associated with adverse perioperative outcomes in cases of spontaneous CSF otorrhea. A thick skull base and the presence of an encephalocele may be protective against recurrence. The effect of untreated intracranial hypertension on the results is unknown.
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Affiliation(s)
- Shawn M Stevens
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Wesley R McIlwain
- Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Paul R Lambert
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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O’Connell BP, Stevens SM, Xiao CC, Meyer TA, Schlosser RJ. Lateral Skull Base Attenuation in Patients with Anterior Cranial Fossa Spontaneous Cerebrospinal Fluid Leaks. Otolaryngol Head Neck Surg 2016; 154:1138-44. [DOI: 10.1177/0194599816630738] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/14/2016] [Indexed: 11/17/2022]
Abstract
Objective (1) Determine if patients with anterior fossa spontaneous cerebrospinal fluid (SCSF) leaks demonstrate lateral skull base bone attenuation. (2) Examine the relation between body mass index (BMI; kg/m2) and skull base thickness. Study Design Retrospective cohort study. Setting Tertiary care hospital. Subjects and Methods Retrospective review from 2004 to 2013 identified 96 patients with anterior cranial fossa SCSF leaks. A control group was identified from a consecutive series of clinic patients. Controls had no history of chronic sinonasal or temporal bone pathology and were divided according to BMI into nonobese (<30 kg/m2) and obese (≥30 kg/m2) groups. Composite skull base thickness was calculated for lateral and anterior subsites through predefined points according to previously published protocols. Results Thirty-two patients were included in each group. Composite lateral skull base thickness was less in patients with SCSF leaks(0.7 ± 0.1 mm) when compared with nonobese controls (0.8 ± 0.1 mm, P = .004); no differences were apparent when SCSF leaks were compared with obese controls (0.7 ± 0.1 mm, P = .99). A direct relation was observed between anterior skull base and lateral skull base thickness ( r = 0.48, P < .0001). An inverse correlation was noted between BMI and lateral skull base ( r =−0.40, P < .0001). Conclusions Patients with anterior fossa SCSF leaks demonstrate attenuation of the lateral skull base. A significant correlation between anterior skull base thickness and lateral skull base thickness was observed. BMI was inversely related to lateral skull base thickness. Taken together, SCSF leaks are associated with obesity, which appears to be partly responsible for diffuse skull base erosion observed in patients with this condition.
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Affiliation(s)
- Brendan P. O’Connell
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shawn M. Stevens
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Otolaryngology–Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christopher C. Xiao
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ted A. Meyer
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rodney J. Schlosser
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Spontaneous Transethmoidal Meningoceles in Adults: Case Series with Emphasis on Surgical Management. ScientificWorldJournal 2016; 2016:3238297. [PMID: 26989762 PMCID: PMC4771905 DOI: 10.1155/2016/3238297] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/24/2016] [Indexed: 11/18/2022] Open
Abstract
Background. Spontaneous onset transethmoidal meningocele is a rare entity among the adult population. Methods. A retrospective chart review was performed and cases of adults diagnosed with spontaneous transethmoidal meningoceles from November 2000 till February 2014 were reported. Data collected included demographics, clinical presentation, diagnostic modalities, and results. Intraoperative findings, the type of surgical reconstruction performed, and the percentage of recurrence, if present, were also reported. Results. Ten cases of spontaneous transethmoidal meningoceles in adults were diagnosed. Eight were females and two males with a mean age of 47.5 years. All patients presented with CSF leakage with or without meningitis. They underwent a reconstruction of the base of skull defect using the temporalis fascia graft in addition to fibrin glue (Tissucol) and Surgicel (Ethicon). In two cases with a larger defect, a piece of septal bone and turbinate mucosa were applied achieving a watertight seal in all cases. Conclusion. Spontaneous transethmoidal meningocele in adults is a rare condition. It usually presents with clear rhinorrhea with or without meningitis and an endoscopic multilayer reconstruction is advocated for treatment of such conditions.
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Pagella F, Pusateri A, Matti E, Zoia C, Benazzo M, Gaetani P, Cazzador D, Volo T, Borsetto D, Emanuelli E. Endoscopic Management of Spontaneous Clival Cerebrospinal Fluid Leaks: Case Series and Literature Review. World Neurosurg 2015; 86:470-7. [PMID: 26626813 DOI: 10.1016/j.wneu.2015.11.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 11/18/2015] [Accepted: 11/19/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Spontaneous cerebrospinal fluid leaks are most commonly located along the anterior skull base. Sphenoidal localization is less common, and clival localization is even rarer. We analyzed a group of patients with spontaneous leaks and selected patients with clival localization. This article discusses surgical management of these entities and provides a brief literature review regarding spontaneous clival leaks. METHODS Of a cohort of 67 patients who presented to our departments with a spontaneous leak during the period 2005-2014, a retrospective data analysis was performed on 6 patients with clival localization of the defect. A skull base repair with a multilayered reconstruction was performed in 3 patients, and a single-layered reconstruction using a pedicled nasoseptal flap was performed in 3 patients. RESULTS The patients included 6 women with a mean age of 60 years (range, 36-91 years). The mean length of the follow-up period was 69.5 months (range, 22-114 months). The overall success rate of the primary endoscopic repair was 83.3% (5 of 6 patients); this increased to 100% after revision surgery. CONCLUSIONS This series, although numerically limited, suggests that a minimally invasive endoscopic repair of idiopathic clival leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Moreover, the pedicled nasoseptal flap has been confirmed to be the "workhorse" for the reconstruction of clival defects.
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Affiliation(s)
- Fabio Pagella
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alessandro Pusateri
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Elina Matti
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Cesare Zoia
- Department of Neurosurgery, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Paolo Gaetani
- Department of Neurosurgery, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Diego Cazzador
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
| | - Tiziana Volo
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
| | - Daniele Borsetto
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
| | - Enzo Emanuelli
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
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Rawal RB, Sreenath SB, Ebert CS, Huang BY, Dugar DR, Ewend MG, Sasaki-Adams D, Senior BA, Zanation AM. Endoscopic sinonasal meningoencephalocele repair: a 13-year experience with stratification by defect and reconstruction type. Otolaryngol Head Neck Surg 2015; 152:361-8. [PMID: 25645526 DOI: 10.1177/0194599814561437] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Sinonasal meningoencephalocele is a rare defect, with varying etiologies and treatment strategies. Here we present the largest published series from a single institution of patients with endoscopic repair. The primary goal is to examine rates of success with consideration to accompanying patient demographic data. The secondary goal is to report the results stratified by defect and reconstruction type. DESIGN Retrospective consecutive case series. SETTING Tertiary care academic center. SUBJECTS AND METHODS Consecutive patients with CPT codes for skull base meningoencephalocele repair between May 2000 and March 2013 were reviewed. Patients who specifically had sinonasal defects were included. RESULTS During the study period, 149 cases of sinonasal meningoencephaloceles were managed in 133 patients. Mean follow-up was 21.3 months (range, 0-116). There was a success rate of 88% for initial repair, with mean recurrence time of 8.3 months (range, 0-38), and a success rate of 93.8% for initial recurrence surgery, with 99.3% of ultimate successful repair. All cases were repaired endoscopically. Recurrence rate was not significantly related to location of defect (P = .682), size of defect (P = .434), particular reconstruction technique (P = .163), or etiology (trauma, P = .070). Overall complication rate was 11.3%. CONCLUSION Endoscopic sinonasal meningoencephalocele repair has excellent long-term results and may be considered as a primary approach. Surgeon comfort with a particular technique should be the most important factor used to guide choice of reconstruction.
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Affiliation(s)
- Rounak B Rawal
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Satyan B Sreenath
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charles S Ebert
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Benjamin Y Huang
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Deepak R Dugar
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew G Ewend
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Deanna Sasaki-Adams
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brent A Senior
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Remenschneider AK, Kozin ED, Curtin H, Santos F. Histopathology of idiopathic lateral skull base defects. Laryngoscope 2015; 125:1798-806. [DOI: 10.1002/lary.25366] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/17/2015] [Accepted: 04/06/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Aaron K. Remenschneider
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Elliott D. Kozin
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Hugh Curtin
- Department of Radiology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Felipe Santos
- Department of Otolaryngology; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
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DelGaudio JM, Baugnon KL, Wise SK, Patel ZM, Aiken AH, Hudgins PA. Magnetic resonance cisternogram with intrathecal gadolinium with delayed imaging for difficult to diagnose cerebrospinal fluid leaks of anterior skull base. Int Forum Allergy Rhinol 2015; 5:333-8. [DOI: 10.1002/alr.21475] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/14/2014] [Accepted: 11/18/2014] [Indexed: 11/08/2022]
Affiliation(s)
- John M. DelGaudio
- Department of Otolaryngology, Emory University School of Medicine; Atlanta GA
| | - Kristen L. Baugnon
- Department of Radiology and Imaging Sciences, Section of Head and Neck Radiology, Emory University School of Medicine; Atlanta GA
| | - Sarah K. Wise
- Department of Otolaryngology, Emory University School of Medicine; Atlanta GA
| | - Zara M. Patel
- Department of Otolaryngology, Emory University School of Medicine; Atlanta GA
| | - Ashley H. Aiken
- Department of Radiology and Imaging Sciences, Section of Head and Neck Radiology, Emory University School of Medicine; Atlanta GA
| | - Patricia A. Hudgins
- Department of Radiology and Imaging Sciences, Section of Head and Neck Radiology, Emory University School of Medicine; Atlanta GA
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Rivera D, Fermin-Delgado R, Stoeter P. "Spontaneous" CSF Fistula due to Transtegmental Brain Herniation in Combination with Signs of Increased Intracranial Pressure and Petrous Bone Hyperpneumatization: An Illustrative Case Report. J Neurol Surg Rep 2014; 75:e251-4. [PMID: 25485224 PMCID: PMC4242826 DOI: 10.1055/s-0034-1387183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 06/09/2014] [Indexed: 11/29/2022] Open
Abstract
Background and Importance Transtegmental brain herniation into the petrous bone is a rare cause of rhinoliquorrhea. Our case presents a combination of several typical clinical and imaging findings illustrating the ongoing etiologic discussion of such cerebrospinal fluid (CSF) fistulas. Clinical Presentation A 53-year-old man presented with nasal discharge after a strong effort to suppress coughing. Imaging revealed a transtegmental herniation of parts of the inferior temporal gyrus into the petrous bone and in addition a combination of signs of chronically increased intracranial pressure and a hyperpneumatization of the petrous bone. The fistula was closed by a middle cranial fossa approach. Conclusion The case illustrates the two main predisposing factors for development of petrous bone CSF fistulas: increased intracranial pressure and thinning of the tegmental roof due to extensive development of air cells. Because the CSF leakage repair does not change the underlying cause, patients have to be informed about the possibility of developing increased intracranial pressure and recurrences of brain herniations at other sites.
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Affiliation(s)
- Diones Rivera
- Department of Neurosurgery, CEDIMAT, Plaza de la Salud, Santo Domingo, Republica Dominicana
| | - Rafael Fermin-Delgado
- Department of Radiology, CEDIMAT, Plaza de la Salud, Santo Domingo, Republica Dominicana
| | - Peter Stoeter
- Department of Radiology, CEDIMAT, Plaza de la Salud, Santo Domingo, Republica Dominicana
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Stevens SM, Lambert PR, Rizk H, McIlwain WR, Nguyen SA, Meyer TA. Novel radiographic measurement algorithm demonstrating a link between obesity and lateral skull base attenuation. Otolaryngol Head Neck Surg 2014; 152:172-9. [PMID: 25450407 DOI: 10.1177/0194599814557470] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES (1) To describe a validated algorithm for measuring tegmen thickness on computed tomography scans. (2) To compare the tegmen thickness in 3 groups: patients with spontaneous cerebrospinal fluid (CSF) leaks, obese controls, and nonobese controls. STUDY DESIGN Retrospective review. SETTING Patients with spontaneous CSF otorrhea often have highly attenuated tegmen plates. This is associated with obesity and/or idiopathic intracranial hypertension (IIH). No evidence exists, however, that objectively links obesity and/or IIH with skull base attenuation. SUBJECTS AND METHODS This was a retrospective review from 2004 to the present. Patients with spontaneous CSF otorrhea and matched obese (body mass index [BMI] >30 kg/m(2)) and nonobese (BMI <30 kg/m(2)) controls were selected. Tegmen thickness was measured radiographically. Interrater validity was assessed. RESULTS Ninety-eight patients were measured: 37 in the CSF group (BMI, 36.6 kg/m(2)), 30 in the obese group (BMI, 34.6 kg/m(2)), and 31 in the nonobese group (BMI, 24.2 kg/m(2)). The CSF group had a significantly thinner tegmen compared to both the obese control (P < .01) and nonobese control (P = .0004) groups. Obese controls had a thinner tegmen than nonobese controls (P < .00001). A significant inverse correlation was detected between skull base thickness and BMI. Signs/symptoms of IIH were most commonly found in the CSF group. Good to very good strength of agreement was detected for measures between raters. CONCLUSION This is the first study to (1) quantify lateral skull base thickness and (2) significantly correlate obesity with lateral skull base attenuation. Patients who are obese with spontaneous CSF leaks have greater attenuation of their skull base than matched obese controls. This finding supports theories that an additional process, possibly congenital, has a pathoetiological role in skull base dehiscence.
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Affiliation(s)
- Shawn M Stevens
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Paul R Lambert
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Habib Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Wesley R McIlwain
- Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Chazen JL, Talbott JF, Lantos JE, Dillon WP. MR myelography for identification of spinal CSF leak in spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2014; 35:2007-12. [PMID: 24852289 DOI: 10.3174/ajnr.a3975] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CT myelography has historically been the test of choice for localization of CSF fistula in patients with spontaneous intracranial hypotension. This study evaluates the additional benefits of intrathecal gadolinium MR myelography in the detection of CSF leak. MATERIALS AND METHODS We performed a retrospective review of patients with spontaneous intracranial hypotension who underwent CT myelography followed by intrathecal gadolinium MR myelography. All patients received intrathecal iodine and off-label gadolinium-based contrast followed by immediate CT myelography and subsequent intrathecal gadolinium MR myelography with multiplanar T1 fat-suppressed sequences. CT myelography and intrathecal gadolinium MR myelography images were reviewed by an experienced neuroradiologist to determine the presence of CSF leak. Patient records were reviewed for demographic data and adverse events following the procedure. RESULTS Twenty-four patients met both imaging and clinical criteria for spontaneous intracranial hypotension and underwent CT myelography followed by intrathecal gadolinium MR myelography. In 3/24 patients (13%), a CSF leak was demonstrated on both CT myelography and intrathecal gadolinium MR myelography, and in 9/24 patients (38%), a CSF leak was seen on intrathecal gadolinium MR myelography (P = .011). Four of 6 leaks identified independently by intrathecal gadolinium MR myelography related to meningeal diverticula. CT myelography did not identify any leaks independently. There were no reported adverse events. CONCLUSIONS Present data demonstrate a higher rate of leak detection with intrathecal gadolinium MR myelography when investigating CSF leaks in our cohort of patients with spontaneous intracranial hypotension. Although intrathecal gadolinium is an FDA off-label use, all patients tolerated the medication without evidence of complications. Our data suggest that intrathecal gadolinium MR myelography is a well-tolerated examination with significant benefit in the evaluation of CSF leak, particularly for patients with leak related to meningeal diverticula.
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Affiliation(s)
- J L Chazen
- From the Department of Radiology (J.L.C., J.E.L.), Weill Cornell Medical Center, New York, New York
| | - J F Talbott
- Department of Radiology (J.F.T.), San Francisco General Hospital, San Francisco, California
| | - J E Lantos
- From the Department of Radiology (J.L.C., J.E.L.), Weill Cornell Medical Center, New York, New York
| | - W P Dillon
- Department of Radiology and Biomedical Imaging (W.P.D.), University of California, San Francisco, San Francisco, California
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Management of spontaneous cerebrospinal fluid leaks of the sphenoid sinus: our experience. The Journal of Laryngology & Otology 2014; 128:797-802. [PMID: 25180632 DOI: 10.1017/s0022215114001698] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Closure of spontaneous sphenoid sinus cerebrospinal fluid leaks can be challenging because of the relative inaccessibility of the lateral recess and the presence of intracranial hypertension. We present our experience of such cases and highlight factors associated with a successful outcome. METHODS Eleven patients with spontaneous, laboratory confirmed, sphenoid sinus cerebrospinal fluid leaks were included. All patients underwent endoscopic closure by either a three-layer technique or fat obliteration. RESULTS In all but one patient, the leak was successfully sealed (success rate, 90.9 per cent; mean follow up, 37.1 months). Elevated intracranial pressure was measured in eight patients, two of whom did not exhibit relevant clinical or radiological characteristics. Five patients received diuretics and dietary advice for weight reduction. In one patient with recurrence two weeks after repair, successful revision was performed by additional placement of a ventriculoperitoneal shunt (follow up, 67 months). CONCLUSION Long-lasting cerebrospinal fluid fistula sealing in the sphenoid sinus requires stable reconstruction of the defect in three layers or fat obliteration if the anatomy is unfavourable. All patients should be intra- and post-operatively screened for elevated intracranial pressure to identify those who need additional intracranial pressure reduction measures.
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75
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Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol 2014; 33:330-7. [PMID: 24042170 DOI: 10.1097/wno.0b013e318299c292] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Idiopathic intracranial hypertension (IIH) is increasingly recognized as a cause of spontaneous cerebrospinal fluid (CSF) leak in the otolarnygological and neurosurgical literature. The diagnosis of IIH in patients with spontaneous CSF leaks typically is made a few weeks after surgical repair of the leak when symptoms and signs of elevated intracranial pressure (ICP) appear. METHODS Case reports and literature review. Two young obese women developed spontaneous CSF rhinorrhea related to an empty sella in one and a cribriform plate encephalocele in the other. Both patients underwent surgical repair of the CSF leak. A few weeks later, they developed chronic headaches and bilateral papilledema. Lumbar punctures showed elevated CSF opening pressures with normal CSF contents, with temporary improvement of headaches. A man with a 3-year history of untreated IIH developed spontaneous CSF rhinorrhea. He experienced improvement of his headaches and papilledema after a CSF shunting procedure, and the rhinorrhea resolved after endoscopic repair of the leak. RESULTS These cases and the literature review confirm a definite association between IIH and spontaneous CSF leak based on: 1) similar demographics; 2) increased ICP in some patients with spontaneous CSF leak after leak repair; 3) higher rate of leak recurrence in patients with raised ICP; 4) patients with intracranial hypertension secondary to tumors may develop CSF leak, confirming that raised ICP from other causes than IIH can cause CSF leak. CONCLUSIONS CSF leak occasionally may keep IIH patients symptom-free; however, classic symptoms and signs of intracranial hypertension may develop after a CSF leak is repaired, exposing these patients to a high risk of recurrence of the leak unless an ICP-lowering intervention is performed.
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Fleischman GM, Ambrose EC, Rawal RB, Huang BY, Ebert CS, Rodriguez KD, Zanation AM, Senior BA. Obstructive sleep apnea in patients undergoing endoscopic surgical repair of cerebrospinal fluid rhinorrhea. Laryngoscope 2014; 124:2645-50. [PMID: 24591190 DOI: 10.1002/lary.24661] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 02/05/2014] [Accepted: 02/28/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To examine the relationship between cerebrospinal fluid (CSF) rhinorrhea and obstructive sleep apnea (OSA). STUDY DESIGN Retrospective chart review of patients who underwent surgical repair of encephaloceles and/or CSF rhinorrhea at a tertiary medical center over a 12-year period. METHODS Pertinent demographic, clinical, and surgical data including age, sex, and medical and surgical history were obtained. Patients were classified by etiology of CSF leak into a spontaneous leak group and a nonspontaneous leak group, which included patients with documented trauma, malignancy, or known iatrogenic injury. RESULTS We retrospectively identified 126 patients who underwent repair of encephalocele or CSF rhinorrhea. Of these, 70 (55.5%) were found to have a spontaneous etiology, whereas 56 (44.4%) had a nonspontaneous cause. Patients with spontaneous CSF rhinorrhea were more likely than their nonspontaneous counterparts to have a diagnosis of OSA (30.0% vs. 14.3%, P = .0294) and radiographic evidence of an empty sella on magnetic resonance imaging MRI (55.4% vs. 24.3%, P = .0027). Overall, patients in the spontaneous CSF rhinorrhea group were more likely to be female compared to the nonspontaneous group (84.3% vs. 41.1% female, P = .0001). CONCLUSIONS Our study shows that patients with spontaneous CSF rhinorrhea are significantly more likely to have a diagnosis of OSA compared to those with nonspontaneous causes of CSF leaks, or to the general population (incidence of 1%-5% in various population studies). Given the known association between OSA and intracranial hypertension (ICH), it may be prudent to screen all patients with spontaneous CSF rhinorrhea for symptoms of OSA as well as for ICH, and vice versa. LEVEL OF EVIDENCE 4
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Affiliation(s)
- Gitanjali M Fleischman
- Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University, University Hospitals-Case Medical Center, Cleveland, Ohio, U.S.A
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Abstract
OBJECTIVE MRI abnormalities have been described in patients with increased intracranial pressure (ICP), including in those with idiopathic intracranial hypertension (IIH). Spontaneous CSF-filled outpouchings of the dura (meningoceles) and secondary CSF leaks can occur from elevated ICP in patients with IIH; however, few studies have evaluated these findings. Our objective was to evaluate the frequency of spontaneous intracranial meningoceles among IIH patients and determine their association with visual outcome. MATERIALS AND METHODS We performed a retrospective case-control study of consecutive IIH patients between 2000 and 2011 who underwent MRI that included T2-weighted imaging. Demographics, presenting symptoms, CSF opening pressure, and visual outcome were collected for the first and last evaluations. Control subjects included patients without headache or visual complaints who had normal brain MRI results. Stratified analysis was used to control for potential confounding by age, sex, race, and body mass index. RESULTS We included 79 IIH patients and 76 control subjects. Meningoceles were found in 11% of IIH patients versus 0% of control subjects (p<0.003). Prominent Meckel caves without frank meningoceles were found in 9% of IIH patients versus 0% of control subjects (p<0.003). Among IIH patients, the presence of meningocele or prominent Meckel caves was not associated with demographics, symptoms, degree of papilledema, CSF opening pressure, visual acuity, or visual field defect severity. CONCLUSION Meningoceles are significantly more common in IIH patients than in control subjects and can be considered an additional imaging sign for IIH. Meningoceles are not, however, associated with decreased CSF opening pressure or better visual outcome in IIH.
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Settecase F, Harnsberger HR, Michel MA, Chapman P, Glastonbury CM. Spontaneous lateral sphenoid cephaloceles: anatomic factors contributing to pathogenesis and proposed classification. AJNR Am J Neuroradiol 2014; 35:784-9. [PMID: 24091443 DOI: 10.3174/ajnr.a3744] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SUMMARY Spontaneous lateral sphenoid cephaloceles arise from bony defects in the lateral sphenoid, in the absence of predisposing factors such as trauma, surgery, mass, or congenital skull base malformation. We reviewed CT and MR imaging findings and clinical data of 26 patients with spontaneous lateral sphenoid cephaloceles to better understand anatomic contributions to pathogenesis, varying clinical and imaging manifestations, and descriptive terminology. Two types of spontaneous lateral sphenoid cephaloceles were identified. In 15 of 26 patients, a type 1 spontaneous lateral sphenoid cephalocele was noted, herniating into a pneumatized lateral recess of the sphenoid sinus, and typically presenting with CSF leak and/or headache. In 11 of 26 patients, a type 2 spontaneous lateral sphenoid cephalocele was noted, isolated to the greater sphenoid wing without extension into the sphenoid sinus, presenting with seizures, headaches, meningitis, cranial neuropathy, or detected incidentally. All patients had sphenoid arachnoid pits, and 61% of patients had an empty or partially empty sella, suggesting that altered CSF dynamics may play a role in their genesis.
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Affiliation(s)
- F Settecase
- From the Department of Radiology and Biomedical Imaging (F.S., C.M.G.) University of California, San Francisco, San Francisco, California
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Van Zele T, Kitice A, Vellutini E, Balsalobre L, Stamm A. Primary spontaneous cerebrospinal fluid leaks located at the clivus. ALLERGY & RHINOLOGY 2013; 4:e100-4. [PMID: 24124635 PMCID: PMC3793111 DOI: 10.2500/ar.2013.4.0053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Transclival meningoceles and primary spontaneous cerebrospinal fluid (CSF) leaks at the clivus are extremely rare lesions and only few of them have been reported in the literature. We report here six cases of transclival primary spontaneous CSF leaks through the clivus. A retrospective case study was performed. We reviewed six cases involving sinonasal CSF leaks located at the clivus treated between 1997 and 2009. Presenting symptoms, duration of symptoms, defect size, site of defect, surgical approach and technique of defect closure, intraoperative complications, postoperative complications, and recurrences are discussed. All CSF leaks were located in the upper central part of the clivus. two of six patients showed signs of increased intracranial pressure (ICP) including arachnoid pits and/or empty sella. For three patients a purely transnasal approach was used with multilayer reconstruction using a nonvascularized graft, and three patients underwent a transnasal transseptal approach with a multilayer reconstruction, with nasoseptal flap. No recurrences of CSF leaks at clivus or other sites were observed to date with a mean follow-up of 10.3 years (range, 3-15 years). Spontaneous CSF rhinorrhea located at the clivus is an extremely rare condition. To date, only eight cases have been described. Here, we report the largest group of six consecutive cases. Irrespective of the used reconstruction technique in all cases a 100% closure rate was achieved. However, identification of increased ICP is an essential aspect and this condition should be treated either medically or surgically.
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Affiliation(s)
- Thibaut Van Zele
- Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
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Preuss M, Steinhoff A, Zühlke CJ, Schulz D, Stein M, Nestler U, Christophis P. Pathophysiology and treatment options in trigeminal meningoceles. J Neurol Surg Rep 2013; 74:81-7. [PMID: 24303342 PMCID: PMC3836919 DOI: 10.1055/s-0033-1348955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 04/13/2013] [Indexed: 10/28/2022] Open
Abstract
Trigeminal meningoceles, lateral to the maxillary nerve (V2), have seldom been reported as underlying pathology for spontaneous rhinoliquorrhea. In contrast to sphenoid meningoceles arising from a persistent lateral craniopharyngeal canal (Sternberg-Cruveilhier, medial to V2), their occurrence seems to be generated by addition of erosive processes to the constitutively thin bony shell underneath the semilunar ganglion, lateral to the round foramen (and V2). The developmental and anatomical relationships of trigeminal meningoceles to the sphenoid bone are depicted, and in a review of the literature we present the different surgical approaches employed for sealing the dura leak. In view of these techniques we discuss an unusual case of therapy-resistant rhinoliquorrhea with left-sided trigeminal meningocele involving the Meckel cave at the lateral sphenoid and reaching the superior orbital fissure and the medial orbital space. In contrast to patients who have lateral sphenoidal meningoceles with a persistent lateral craniopharyngeal canal (Sternberg-Cruveilhier), who can be treated successfully using an endoscopic transsphenoidal approach (recurrence rate 13.7%), the recurrence rate of cerebrospinal fluid (CSF) efflux for trigeminal meningoceles lies much higher (endoscopically 66%, open craniotomy 33%). The surgical strategy thus has to be chosen individually, taking into account specific anatomical situations and eventually preceding operations.
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Affiliation(s)
- Matthias Preuss
- Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
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Soni RS, Choudhry OJ, Liu JK, Eloy JA. Postoperative cerebrospinal fluid leak after septoplasty: A potential complication of occult anterior skull base encephalocele. ALLERGY & RHINOLOGY 2013; 4:e41-4. [PMID: 23772326 PMCID: PMC3679567 DOI: 10.2500/ar.2013.4.0043] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Postoperative cerebrospinal fluid (CSF) rhinorrhea after septoplasty is a known entity resulting from errors in surgical technique and improper handling of the perpendicular plate of the ethmoid bone. When these occur, urgent management is necessary to prevent deleterious sequelae such as meningitis, intracranial abscess, and pneumocephalus. Encephaloceles are rare occurrences characterized by herniation of intracranial contents through a skull base defect that can predispose patients to CSF rhinorrhea. In this report, we present a case of CSF rhinorrhea occurring 2 weeks after septoplasty likely from manipulation of an occult anterior skull base encephalocele. To our knowledge, no previous similar case has been reported in the literature. Otolaryngologists should be aware of the possibility of occult encephaloceles while performing septoplasties because minimal manipulation of these entities may potentially result in postoperative CSF leakage.
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Affiliation(s)
- Resha S Soni
- Departments of Otolaryngology-Head and Neck Surgery, and
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Spontaneous Cerebrospinal Fluid Otorrhea and Rhinorrhea in Idiopathic Intracranial Hypertension Patients. J Neuroophthalmol 2013; 33:113-6. [DOI: 10.1097/wno.0b013e18274b870] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Junet P, Bertolo A, Schmerber S. Spontaneous osteo-dural fistulae of petrous bone posterior wall. Eur Ann Otorhinolaryngol Head Neck Dis 2013; 130:341-3. [PMID: 23725664 DOI: 10.1016/j.anorl.2012.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 08/04/2012] [Accepted: 09/20/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To raise awareness of the possibility of spontaneous temporal bone cerebrospinal fistula in case of clear retrotympanic effusion. CASE REPORT A 63-year-old man with no particular history presented with unilateral spontaneous right retrotympanic clear effusion. CT found defects in the posterior part of the right temporal bone, in contact with arachnoid granulations, with no other visible abnormalities. DISCUSSION/CONCLUSION Unilateral clear retrotympanic effusion in an adult subject should, apart from serous otitis media, suggest possible cerebrospinal fistula. In the absence of otologic or traumatic history, arachnoid granulation is one possible etiology, inducing spontaneous cerebrospinal fluid leakage when facing the temporal bone. Diagnosis is suggested by bone defects in the tegmen tympani or posterior wall of the temporal bone on CT, with the adjacent mastoid cavities filled with fluid. Pneumococcal vaccination and early surgical repair of the fistula should be performed to avoid neuromeningeal infection.
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Affiliation(s)
- P Junet
- Pôle tête et cou, clinique universitaire ORL, CHU de Grenoble, 1, avenue des Maquis-du-Grésivaudan, Grenoble cedex 09, France.
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Singh DK, Singh N, Singh R. Transethmoidal meningocele: an unusual complication of intracranial neoplasm. BMJ Case Rep 2013; 2013:bcr-2013-009200. [PMID: 23580688 DOI: 10.1136/bcr-2013-009200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cranial meningoceles/encephaloceles are congenital malformations characterised by protrusion of the meninges and/or brain parenchyma because of a skull defect. Meningoceles secondary to an intracranial neoplasm have not been reported in the published literature. We report a unique case of a 42-year-old man who presented with a sudden onset of altered sensorium. Transethmoidal meningocele secondary to an intraventricular epidermoid cyst was detected on imaging.
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Affiliation(s)
- Deepak Kumar Singh
- Department of Neurosurgery, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Virk JS, Elmiyeh B, Saleh HA. Endoscopic management of cerebrospinal fluid rhinorrhea: the charing cross experience. J Neurol Surg B Skull Base 2013; 74:61-7. [PMID: 24436890 DOI: 10.1055/s-0033-1333620] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 10/20/2012] [Indexed: 10/27/2022] Open
Abstract
Objective To describe our experience of cerebrospinal fluid (CSF) rhinorrhea management. Design Retrospective. Setting Charing Cross Hospital, London, a tertiary referral center. Participants Fifty-four patients with CSF rhinorrhea managed from 2003 to 2011. Main outcome measures Surgical technique; Recurrence. Results Etiologically, 36 were spontaneous and 18 traumatic. Eight patients with spontaneous and two with traumatic leaks had previous failed repairs in other units. Success rates after first and second surgery were 93% and 100%, respectively. Mean follow-up was 21 months. Four patients, all of spontaneous etiology, had recurrences; three of these underwent successful second repair with three layered technique, and the fourth had complete cessation of the leak after gastric bypass surgery and subsequent weight reduction. Adaptation of anatomic three-layered repair since then averted any further failure in the following 7 years. Mean body mass index was 34.0 kg/m(2) in spontaneous and 27.8 kg/m(2) in traumatic cases (p < 0.05). Fifty percent of spontaneous leaks were from the cribriform plate, 22% sphenoid, 14% ethmoid, and 14% frontal sinus. In the traumatic CSF leak group: 33.3% were from the cribriform plate, 33.3% sphenoid, 22.2% ethmoid, and 11.1% frontal. Conclusion Endoscopic CSF fistula closure is a safe and effective operation. All sites of leak can be accessed endoscopically. We recommend the use of an anatomic three-layered closure in difficult cases.
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Affiliation(s)
- Jagdeep Singh Virk
- Department of ENT, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom
| | - Behrad Elmiyeh
- Department of ENT, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom
| | - Hesham A Saleh
- Department of ENT, Charing Cross Hospital, Imperial College Healthcare, London, United Kingdom
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