1
|
Bonomo G, Bussone G, Gans A, Iess G, Bonomo R, Restelli F, Falco J, Mazzapicchi E, Stanziano M, Amato A, Broggi M, Acerbi F, Ferroli P, Schiariti M. Small spheno-ethmoidal meningoencephalocele versus ethmoidal mucocele in spontaneous intracranial hypotension. BRAIN & SPINE 2023; 3:102676. [PMID: 38021026 PMCID: PMC10668106 DOI: 10.1016/j.bas.2023.102676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/07/2023] [Accepted: 09/17/2023] [Indexed: 12/01/2023]
Abstract
Background Meningoencephalocele is defined as an abnormal sac of brain tissue and meninges extending beyond natural skull margins, often leading to cerebrospinal fluid (CSF) leakage. When this condition arises in the spheno-ethmoidal region, the diagnosis becomes more challenging as it can be mistaken for other nasal pathologies, such as mucocele. Research question We show in this case report a non-congenital sphenoethmoidal meningoencephalocele causing rhinoliquoral fistula and spontaneous intracranial hypotension. Results this 65-year-old woman presented with sporadic rhinoliquorrhoea associated with orthostatic headache, nausea and dizziness. Brain MRI revealed a small lesion of an ethmoidal sinus, which was successfully treated with endoscopic endonasal surgery. Histology confirmed the presence of meningoencephalic tissue positive for S100 protein on immunohistochemistry. Conclusions When dealing with lesions of the paranasal sinuses in contact with the anterior skull base, rhinoliquorrhoea presence suggests meningoencephalocele. In dubious cases, a proper workup, including a thorough clinical history and neurological examination, specific imaging, and a direct search of CSF-like markers, is essential to support the differential diagnosis. In such cases, a transnasal endoscopic surgical approach is recommended to obtain a final histological diagnosis and to perform eventual dural plastic surgery.
Collapse
Affiliation(s)
- Giulio Bonomo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Gennaro Bussone
- Department of Neurology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Alessandro Gans
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Guglielmo Iess
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Roberta Bonomo
- Department of Neurology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- School of Medicine and Surgery, Kore University of Enna, Enna, Italy
| | - Francesco Restelli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Elio Mazzapicchi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Mario Stanziano
- Neuroradiology Unit, Diagnostic and Technology Department, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Neurosciences Department “Rita Levi Montalcini”, University of Turin, Turin, Italy
| | - Alessia Amato
- Department of Child Neuropsychiatry, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- University of Milan, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| |
Collapse
|
2
|
Surgical Repair of Skull Base CSF Leaks after Cisternography Diagnosis: Analysis of Validity and Surgical Outcome and Impact on Future Treatment Strategies. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8740352. [PMID: 35528177 PMCID: PMC9076329 DOI: 10.1155/2022/8740352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/09/2022] [Indexed: 11/22/2022]
Abstract
Skull base cerebrospinal fluid (CSF) leaks can lead to severe complications and require appropriate diagnosis and treatment. Cisternography is applied when exact localization via conventional imaging is not successful. The present study is aimed at identifying factors with potential impact on radiological results and surgical success. Cisternography followed by surgical repair due to skull base CSF leaks was performed in 63 cases between 2002 and 2020. The clinical and radiological findings were analyzed retrospectively. The etiology of CSF leaks was traumatic in 30.2%, spontaneous in 36.5%, and iatrogenic in 33.3%. The sensitivity of cisternography was 87.9%. Spontaneous CSF leaks tended to be diagnosed less frequently via cisternography and were significantly less frequently localized intraoperatively. The median postoperative follow-up period was 34 months. The primary surgical success rate was 79.4%, with a significantly higher success rate for lateral than for anterior skull base defects. Surgical failure tended to be lower in iatrogenic and higher in traumatic defects. Cisternography proved to be a highly sensitive method to localize skull base CSF leaks and can be recommended for advanced diagnostics. Iatrogenic leaks seemed to be more likely to have a favorable surgical outcome, whereas traumatic leaks tended to have a lower surgical success rate.
Collapse
|
3
|
Albaharna H, Alshareef M, Alromaih S, Aloulah M, Alsaleh S, Alroqi A. Topical Intranasal Fluorescein to Diagnose and Localize Cerebrospinal Fluid Leak: A Systematic Review. Turk Arch Otorhinolaryngol 2021; 59:223-229. [PMID: 34713008 PMCID: PMC8527542 DOI: 10.4274/tao.2021.2021-3-12] [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: 03/31/2021] [Accepted: 06/14/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: This study evaluates the available evidence regarding using topical intranasal fluorescein (TINF) to diagnose and localize nasal cerebrospinal fluid (CSF) leak. Methods: A literature search was conducted through PubMed, the Cochrane Database, Scopus, and Ovid to identify the articles providing insight into using TINF to diagnose CSF leak preoperatively or to localize the leak intraoperatively. The articles from the database were screened and filtered by two authors according to the selection criteria. A spreadsheet was created to collect the data including demographic characteristics, the sensitivity and specificity of TINF for diagnosing and localizing a CSF leak, the protocol of applying TINF, and the complications. Results: After excluding duplicates and articles that did not meet our selection criteria, we included five reports in the final analysis. The average age of the 94 participants was 39.5, and there was an equal distribution of males and females. The sensitivity of TINF to make a preoperative diagnosis of CSF leak was 100%, and it was 97% to localize the site intraoperatively. Complications associated with TINF were not reported in any of the reports. This review showed a grade C recommendation based on five case series. Conclusion: Based on the current evidence, TINF cannot be recommended for standard clinical practice. It can, however, be considered in situations where other gold standard tools are unavailable since it is feasible and easy to use. A standardized control trial should be conducted to yield additional unbiased evidence.
Collapse
Affiliation(s)
- Hussain Albaharna
- Department of Otolaryngology-Head and Neck surgery, Qatif Central Hospital, Qatif, Eastern province, Saudi Arabia.,Department of Otolaryngology-Head & Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Alshareef
- Department of Otolaryngology-Head and Neck Surgery, Khamis Mushait General Hospital, Khamis Mushait City, Saudi Arabia.,Department of Otolaryngology-Head & Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Saud Alromaih
- Department of Otolaryngology-Head & Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Aloulah
- Department of Otolaryngology-Head & Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Saad Alsaleh
- Department of Otolaryngology-Head & Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Alroqi
- Department of Otolaryngology-Head & Neck Surgery, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
4
|
Rampinelli V, Mattavelli D, Ferrari M, Schreiber A, Ravanelli M, Farina D, Deganello A, Fontanella MM, Doglietto F, Nicolai P. Management of anterior fossa cephaloceles. J Neurosurg Sci 2020; 65:140-150. [PMID: 33320465 DOI: 10.23736/s0390-5616.20.05099-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Skull base cephaloceles (SBCs) are defined as herniation of intracranial content through the skull base and are classified based on composition, etiology, and topographic location. Anterior SBCs frequently protrude in the sinonasal cavity, and consequently are at potential risk of infection. Therefore, the current recommendation is to treat SBCs with the primary intent of preventing meningitis, and surgery represents the mainstay of treatment. Anterior SBCs may display a wide spectrum of severity and complexity, and in each case the risks and benefits of surgical approaches are to be carefully weighted based on thorough assessment of symptoms, age, general conditions, location and size of the lesion, as well as expertise of the surgeon. In the last 30 years, the evolution and diffusion of transnasal endoscopic surgery have substantially changed the surgical management of the majority of SBC. In the past, they were treated exclusively with open transcranial approaches that may be burdened by relevant morbidity and risk for severe complications. The transnasal endoscopic corridor now provides easy access to the lesion and different reconstructive strategies using endonasal pedicled flaps, without any external incision, cranioplasty or brain manipulation. However, there are still scenarios in which an exclusive transnasal endoscopic route is contraindicated. The aim of the present review was to provide an overview on the comprehensive management of anterior SBC, with a particular focus on lesions suitable for endoscopic surgery. Furthermore, special aspects of SBC management in children and adults will be highlighted.
Collapse
Affiliation(s)
- Vittorio Rampinelli
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Section of Otorhinolaryngology, Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Farina
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology, Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy -
| | - Piero Nicolai
- Section of Otorhinolaryngology, Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| |
Collapse
|
5
|
Chorath K, Krysinski M, Bunegin L, Majors J, Weitzel EK, McMains KC, Chen PG. Failure Pressures of Dural Repairs in a Porcine Ex Vivo Model: Novel Use of Titanium Clips Versus Tissue Glue. ALLERGY & RHINOLOGY 2019; 10:2152656719879677. [PMID: 31632835 PMCID: PMC6769216 DOI: 10.1177/2152656719879677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective Endoscopic skull base surgery is advancing, and it is important to have reliable methods to repair the resulting defect. The objective of this study was to determine the failure pressures of 2 commonly used methods to repair large dural defects: collagen matrix underlay with fibrin glue and collagen matrix underlay with polyethylene glue, as well as a novel repair method: fascia lata with nonpenetrating titanium vascular clips. Methods The failure pressure of the 3 dural repairs was determined in a closed testing apparatus. Defects in porcine dura were created and collagen matrix grafts were used as an underlay followed by either fibrin glue (FG/CMG) or polyethylene glycol glue (PEG/CMG). A third condition using a segment of fascia lata was positioned flush with the edges of the dural defect and secured with titanium clips (TC/FL). Saline was infused to simulate increasing intracranial pressure (ICP) applied to the undersurface of the grafts until the repairs failed. Results The mean failure pressure of the PEG/CMG repair was 34.506 ± 14.822 cm H2O, FG/CMG was 12.413 ± 5.114 cm H2O, and TC/FL was 8.330 ± 3.483 cm H2O. There were statistically significant differences in mean failure pressures among the 3 repair methods. Conclusion In this ex vivo model comparing skull base repairs’ ability to withstand cerebrospinal fluid leak, the repairs that utilized PEG/CMG tolerated the greatest amount of pressure and was the only repair that exceeded normal physiologic ICP’s. Repair methods utilizing glues generally tolerated higher pressures compared to the novel repair using clips alone.
Collapse
Affiliation(s)
- Kevin Chorath
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Mason Krysinski
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Leonid Bunegin
- Department of Anesthesiology, University of Texas Health San Antonio, San Antonio, Texas
| | - Jacob Majors
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Erik Kent Weitzel
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Kevin Christopher McMains
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, Texas
| | - Philip G Chen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health San Antonio, San Antonio, Texas
| |
Collapse
|
6
|
Eide JG, Walz P, Alden TD, Rastatter JC. Pediatric skull base surgery: Encephaloceles and cerebrospinal fluid leaks. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.otot.2019.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
7
|
Success Rate and Complications of Cerebrospinal Fluid Rhinorrhea Treated With a Transcranial Approach. J Craniofac Surg 2018; 29:e808-e812. [PMID: 30320681 DOI: 10.1097/scs.0000000000004845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to evaluate the clinical outcomes of cerebrospinal fluid (CSF) rhinorrhea in patients treated with transcranial surgery. Here, we retrospectively reviewed 23 patients with CSF rhinorrhea between 2008 and 2015 at our university hospital. Nine (39.1%) patients were treated conservatively, whereas 12 (52.2%) patients were treated with a transcranial approach. Our results showed that 7 (30.4%), 11 (47.8%), and 5 (21.7%) patients had spontaneous, traumatic, and iatrogenic CSF leakage, respectively. In our study, the cribriform plate was the most common site of leakage, and it was found to be involved in 5 (21.7%) patients. The mean diameter defect of the fistula was 130.40 ± 190.47 mm and there was no significant difference between this defect and the different etiology types. In our study, meningitis, third nerve palsy, and vasospasm were the main complications that arose during the treatment of CSF rhinorrhea. Moreover, 6 (26.1%) of 7 (30.4%) patients had spontaneous CSF leaks that were treated with surgery. Notably, spontaneous CSF leaks did not stop when treated with conservative measures. In addition, there were no significant differences between etiology types and CSF leaks. The primary surgical repair rate was 78.3% and the secondary surgery repair rate was 91.6%. Importantly, as we preferred using this type of transcranial surgery in our clinic, there has been a higher success rate with endoscopic treatments and fewer major complications from CSF rhinorrhea in the literature.
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Visual and Quantitative Analysis of Cisternography for the Detection of Cerebrospinal Fluid Leakage. Nucl Med Mol Imaging 2017; 51:193-194. [PMID: 28559947 DOI: 10.1007/s13139-015-0389-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/25/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022] Open
Abstract
We herein present a case of a 29-year-old man with clear rhinorrhea, which persisted for 8 years following a myringotomy. After cotton pledgets were placed in several different regions of the nasal cavity, cisternography using Tc-99m DTPA was performed to measure the radioactivity of each pledget. Cisternography showed subtle uptake in the nasal cavity. However, intense uptake was detected in the pledget placed in the right eustachian tube orifice, where the pledget:serum count ratio was 10.3:1. The patient underwent duroplasty and cranioplasty, and the rhinorrhea resolved.
Collapse
|
10
|
Baban MIA, Hadi M, Gallo S, Zocchi J, Turri-Zanoni M, Castelnuovo P. Radiological and clinical interpretation of the patients with CSF leaks developed during or after endoscopic sinus surgery. Eur Arch Otorhinolaryngol 2017; 274:2827-2835. [PMID: 28447154 DOI: 10.1007/s00405-017-4587-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 04/22/2017] [Indexed: 11/26/2022]
Abstract
Cerebrospinal fluid (CSF) leaks associated with endoscopic sinus surgery (ESS) are a rare complication related to anatomical and technical factors. The anatomical variations at skull base level are imperative to be detected preoperatively by CT scan to avoid this complication. Identifying the factors playing a role in the incidence of the CSF leaks during and after ESS and the common leak sites. A retrospective review of 24 patients presented with incidental CSF leaks, gathered from 1999 to 2016 was performed. Images interpretation of the skull base area was done using four parameters includes Keros classification, skull base slope, fovea plane and maxillary ethmoid height ratio (MER). Each parameter is classified into three types according to the anatomical configuration, then these parameters scores categorized according to the level of the safety into a level I, II and III, all levels were correlated with each other and with the site of leakage. It was found that the major group presented with the level I and the least group with level III safety, with an evidence of the most unsafe anatomical variation was the least relevant. Parameters measurements revealed that the larger group of the anatomical variation type III was in the MER and the commonest leak site was in the posterior ethmoidal roof. CT scan study of the skull base is crucial in delineating the variations and be a roadmap to proceed safely through the dissection remembering that incidental CSF leaks are multifactorial in etiology.
Collapse
Affiliation(s)
- Muaid I Aziz Baban
- Unit of Otorhinolaryngology, Department of Surgery, School of Medicine, University of Sulaymaniyah, Kurdistan, Iraq.
| | - Mokarbesh Hadi
- Unit of Otorhinolaryngology, Prince Mohammed Bin Naser Hospital, Jazan, Saudi Arabia
| | - Stefania Gallo
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
- Head and Neck Surgery and Forensic Dissection Research Center (HNS and FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Jacopo Zocchi
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Mario Turri-Zanoni
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
- Head and Neck Surgery and Forensic Dissection Research Center (HNS and FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
- Head and Neck Surgery and Forensic Dissection Research Center (HNS and FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| |
Collapse
|
11
|
Yadav YR, Parihar V, Janakiram N, Pande S, Bajaj J, Namdev H. Endoscopic management of cerebrospinal fluid rhinorrhea. Asian J Neurosurg 2016; 11:183-93. [PMID: 27366243 PMCID: PMC4849285 DOI: 10.4103/1793-5482.145101] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.
Collapse
Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Narayanan Janakiram
- Department of Otolaryngology, Royal Pearl Hospital, Trichy, Tamil Nadu, India
| | - Sonjay Pande
- Department of Radio Diagnosis, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Hemant Namdev
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| |
Collapse
|
12
|
Zhang Y, Wang F, Chen X, Zhang Z, Meng X, Yu X, Zhou T. Cerebrospinal fluid rhinorrhea: evaluation with 3D-SPACE sequence and management with navigation-assisted endonasal endoscopic surgery. Br J Neurosurg 2016; 30:643-648. [PMID: 27340877 DOI: 10.1080/02688697.2016.1199787] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study aimed to assess the efficacy of MR images with three-dimensional sampling perfection with application optimised contrast using different flip-angle evolution (3D-SPACE) sequence for detecting cerebrospinal fluid (CSF) rhinorrhea and image-guided surgery for the management of CSF rhinorrhea. MATERIALS AND METHODS This study included 45 consecutive patients with suspected CSF rhinorrhea from 2010 to 2015. Patients underwent preoperative MRI scan including 3D-SPACE and conventional T2-weighted (T2W) protocol. Two-blinded neuroradiologists determined the presence and location of CSF leakage. Imaging results were compared with surgical findings and/or β-2 transferrin testing. Intraoperative navigation was used during endonasal endoscopic surgery for repairing CSF rhinorrhea. RESULTS 3D-SPACE sequence correctly described 27 cases (93.1%) and conventional T2W sequence described only 20 (69.0%) of the total 29 patients with truly positive CSF leakage. The sensitivity, specificity, positive predictive value and negative predictive value for detecting CSF leakages were 93.1%, 87.5%, 93.1%, and 87.5% for 3D-SPACE, and 69.0%, 81.3%, 87.0% and 59.1% for T2W, respectively. To repair the leakage, 3D-SPACE image-guided navigation was used to locate the CSF leakage sites intraoperatively. Only two CSF leakage sites proved by surgery were missed by navigation. Successful endoscopic repairs were achieved in 25 of 26 (96.2%) patients during the first attempt. During the follow-up, there were no major postoperative complications or recurrences encountered. CONCLUSION MR imaging with 3D-SPACE sequence is an effective and reliable method with higher sensitivity and specificity than T2W for detecting CSF leakage. Intraoperative 3D-SPACE image-guided navigation is helpful in locating the sites of the CSF leakage during endonasal endoscopic surgery.
Collapse
Affiliation(s)
- Yanyang Zhang
- a Department of Neurosurgery , PLA General Hospital , Beijing , China
| | - Fuyu Wang
- a Department of Neurosurgery , PLA General Hospital , Beijing , China
| | - Xiaolei Chen
- a Department of Neurosurgery , PLA General Hospital , Beijing , China
| | - Zhizhong Zhang
- a Department of Neurosurgery , PLA General Hospital , Beijing , China
| | - Xianghui Meng
- a Department of Neurosurgery , PLA General Hospital , Beijing , China
| | - Xinguang Yu
- a Department of Neurosurgery , PLA General Hospital , Beijing , China
| | - Tao Zhou
- a Department of Neurosurgery , PLA General Hospital , Beijing , China
| |
Collapse
|
13
|
El-Tarabishi MN, Fawaz SA, Sabri SM, El-Sharnobi MM, Sweed A. A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess. Eur Arch Otorhinolaryngol 2016; 273:4305-4314. [PMID: 27295175 DOI: 10.1007/s00405-016-4125-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
Spontaneous cerebrospinal fluid leak with meningoencephaloceles in sphenoid sinus lateral recess is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of this study is to assess the real effectiveness of a modification of the endoscopic endonasal approach for their management. This is a prospective case series study and was conducted at Otolaryngology department, Ain Shams University Hospitals, Cairo, Egypt. Seven patients with spontaneous cerebrospinal fluid leak with meningoencephaloceles in the sphenoid sinus lateral recess were included. Diagnosis was confirmed by: analysis for beta-2 transferrin and imaging. They were managed with endoscopic endonasal retrograde trans-sphenoid approach described in this study with multilayered reconstruction of the defect. Mean age of our patients was 40.14 ± 8.35 years; mean BMI was 36.37 ± 2.59 kg/m2. Primary empty sella was present and osteodural defect was identified in superior wall of sphenoid sinus lateral recess with punched out and regular smooth edges. Mean intra-cranial pressure was (26.42 ± 3.87 mmH2O) and size of defect was less than 10 mm, mean 7.85 ± 1.34. Mean-operative time was 169.28 ± 21.87 min. The mean hospital stay was 7.42 ± 1.39 days. No cerebrospinal fluid leak recurrences were observed during follow-up period that ranged from 37 to 48 months. Endoscopic endonasal retrograde trans-sphenoid approach provides a wide, safe, and direct route to the management of sphenoid sinus lateral recess cerebrospinal fluid leak.
Collapse
Affiliation(s)
- M N El-Tarabishi
- Otolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - S A Fawaz
- Otolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - S M Sabri
- Otolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - M M El-Sharnobi
- Otolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Sweed
- Otolaryngology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
- Mid Cheshire Hospitals NHS Foundation Trust, Leighton Hospital, Middlewich Road, Crewe, Cheshire, CW1 4QJ, UK.
| |
Collapse
|
14
|
Lin RP, Weitzel EK, Chen PG, McMains KC, Chang DR, Braxton EE, Majors J, Bunegin L. Failure pressures after repairs of 2-cm × 2.5-cm rhinologic dural defects in a porcine ex vivo model. Int Forum Allergy Rhinol 2016; 6:1034-1039. [DOI: 10.1002/alr.21804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/21/2016] [Accepted: 04/09/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Ryan P. Lin
- Uniformed Services University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium; Joint Base San Antonio; TX
- Department of Otolaryngology-Head and Neck Surgery; University of Texas Health Science Center San Antonio; San Antonio TX
- Department of Anesthesiology; University of Texas Health Science Center San Antonio; San Antonio TX
| | - Erik Kent Weitzel
- Uniformed Services University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium; Joint Base San Antonio; TX
| | - Philip G. Chen
- Department of Otolaryngology-Head and Neck Surgery; University of Texas Health Science Center San Antonio; San Antonio TX
| | - Kevin Christopher McMains
- Uniformed Services University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium; Joint Base San Antonio; TX
| | - Daniel R. Chang
- Department of Otolaryngology-Head and Neck Surgery; University of Texas Health Science Center San Antonio; San Antonio TX
| | - Ernest E. Braxton
- Uniformed Services University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium; Joint Base San Antonio; TX
| | - Jacob Majors
- Uniformed Services University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium; Joint Base San Antonio; TX
| | - Leon Bunegin
- Department of Anesthesiology; University of Texas Health Science Center San Antonio; San Antonio TX
| |
Collapse
|
15
|
Abstract
Cerebrospinal fluid (CSF) leak occurs from traumatic, iatrogenic, and idiopathic etiologies. Its timely diagnosis requires clinical, radiographic, and laboratory testing. Medical and surgical management can mitigate the risk of life-threatening infection and morbidity. This article outlines the pathophysiology, diagnosis, and management or CSF leak of the anterior skull base.
Collapse
|
16
|
|
17
|
The benefit of early lumbar drain insertion in reducing the length of CSF leak in traumatic rhinorrhea. Clin Neurol Neurosurg 2016; 142:43-47. [DOI: 10.1016/j.clineuro.2016.01.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 12/30/2015] [Accepted: 01/10/2016] [Indexed: 11/22/2022]
|
18
|
Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.
Collapse
Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
| |
Collapse
|
19
|
Reyes C, Solares CA. Endoscopic Repair of Frontal Sinus Cerebrospinal Fluid Leaks after Firearm Injuries: Report of Two Cases. J Neurol Surg Rep 2015; 76:e8-e12. [PMID: 26251818 PMCID: PMC4520984 DOI: 10.1055/s-0034-1387194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Accepted: 06/28/2014] [Indexed: 11/09/2022] Open
Abstract
Objectives To describe two cases of cerebrospinal fluid (CSF) leak repair after gunshot wound to the head. Design Retrospective review of two cases. Settings A large regional tertiary care facility. Participants Two patients with gunshot wounds to the skull base. Main Outcome Measures Preoperative and postoperative physical and radiologic findings. Results Patients in this series underwent endoscopic surgery, debridement, and repair of CSF leaks after gunshot wounds to the head. To date, the patients are without CSF leak. Conclusions Endoscopic closure of anterior skull base CSF leaks in patients with gunshot wounds can be safe and effective. Treatment should be decided by the severity of neurologic deterioration throughout the emergency period and the existence or absence of associated intracranial lesions. Timing for surgery should be decided with great care and with a multidisciplinary approach.
Collapse
Affiliation(s)
- Camilo Reyes
- Department of Otolaryngology, Universidad del Rosario, Bogota, Colombia
| | - C Arturo Solares
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, United States ; Center for Skull Base Surgery, Georgia Regents University, Augusta, Georgia, United States
| |
Collapse
|
20
|
Lin RP, Weitzel EK, Chen PG, McMains KC, Majors J, Bunegin L. Failure pressures of three rhinologic dural repairs in a porcine ex vivo model. Int Forum Allergy Rhinol 2015; 5:633-6. [PMID: 25763905 DOI: 10.1002/alr.21513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/02/2015] [Accepted: 01/27/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objective of this work was to determine the failure pressures of 3 commonly performed repair techniques of 5-mm dural defects in a controlled setting. METHODS This was a pig dura ex vivo study. A testing apparatus was fabricated to study failure pressures of 3 different repairs in a porcine model. Five-millimeter (5-mm) dural defects were created and plugged with autologous mucosa/Tisseel (MT) (Baxter International Inc.), fat graft (FG), and bath plug (BP) techniques. Saline solution was infused at 30 mL/hour to apply unidirectional pressure to the repair until failure occurred. Five dural repairs were performed for each arm of the trial, for a total of 15 trials. RESULTS The mean failure pressure of the MT repair was 4.3 ± 1.9 cmH2 O, of the FG repair was 10.9 ± 4.2 cmH2 O, and of the BP repair was 20.7 ± 2.2 cmH2 O. Differences among mean failure pressures were statistically significant. CONCLUSION The BP repair showed significantly higher tolerances for pressure than the other 2 repairs. The BP repair was the only technique that withstood adult physiologic supine cerebrospinal fluid (CSF) pressure.
Collapse
Affiliation(s)
- Ryan P Lin
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, TX, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.,Department of Anesthesiology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Erik Kent Weitzel
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, TX, USA
| | - Philip G Chen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Kevin Christopher McMains
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, TX, USA
| | - Jacob Majors
- Uniformed Services, University of Health Sciences and San Antonio Uniformed Health Sciences Educational Consortium, Joint Base San Antonio, San Antonio, TX, USA
| | - Leonid Bunegin
- Department of Anesthesiology, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| |
Collapse
|
21
|
Bedrosian JC, Anand VK, Schwartz TH. The endoscopic endonasal approach to repair of iatrogenic and noniatrogenic cerebrospinal fluid leaks and encephaloceles of the anterior cranial fossa. World Neurosurg 2015; 82:S86-94. [PMID: 25496641 DOI: 10.1016/j.wneu.2014.07.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/24/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The current approach for the diagnosis and repair of spontaneous and traumatic anterior skull-base defects is oulined, highlighting the controversies that exist in the field and describing the strategies required to access different segments of the anterior cranial fossa. METHODS We reviewed the literature concerning endoscopic management of anterior skull-base defects. These publications have been combined with our own experience repairing cerebrospinal fluid (CSF) leaks and encephaloceles that developed spontaneously, traumatically, or intentionally as a result of endoscopic skull-base surgery. RESULTS We present a systematic methodology for the repair of these defects. We have divided our surgical approach into four separate corridors. These are the transnasal, transsphenoidal, transethmoidal, and transmaxillary corridors. Dissection strategies vary for each corridor, but with a combination of approaches, all areas of the anterior skull base can be accessed. Skull-base defects are successfully repaired with a multilayered closure that often involves use of a vascularized pedicled mucosal flap. Adoption of this technique has decreased our rate of postoperative CSF leak from 5.9%-3.1%. CONCLUSIONS Endoscopic endonasal repair of CSF leaks and encephaloceles has evolved significantly during the past decade. The versatility of different endoscopic approaches through the four endonasal corridors allows for the endoscopic repair of almost all skull-base defects. The use of vascularized pedicled mucosal flaps has evolved to cover these defects as part of multilayered closure strategies.
Collapse
Affiliation(s)
- Jeffrey C Bedrosian
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Vijay K Anand
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA; Department of Neurology and Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.
| |
Collapse
|
22
|
Abstract
Background:Post-operative cerebrospinal fluid (CSF) leaks are a common complication of endoscopic pituitary surgery and account for a significant proportion of hospital costs associated with this procedure. Tisseel® is a tissue glue commonly used as an adjunct in dural repair but is not optimal for this purpose. DuraSeal® has several properties advantageous for dural repair but is not widely accepted in Canada partly due to its increased cost.Objective:A cost analysis of DuraSeal® versus Tisseel® in endoscopic pituitary surgery.Methods:A cost analysis was performed based on typical endoscopic pituitary surgery cases performed at our tertiary care institution. Operating room, hospital admission, and surgical sealant costs were obtained directly while estimates of patient recovery time and post-operative CSF leak rates were based on consensus values reported in the literature. Outcomes were reported for various possible clinical scenarios of sealant use.Results:In a model where surgical sealant is employed only in high-risk cases, use of DuraSeal® allows for a yearly cost savings of at least $4486.72. If surgical sealant is used in all cases, regular use of DuraSeal® versus Tisseel® either marginally reduces yearly costs or increases them by a maximum of $7619.25, depending on the case volume and estimated post-operative CSF leak rate.Conclusion:In most clinical scenarios, use of DuraSeal® in endoscopic pituitary surgery may reduce overall yearly hospital costs compared to Tisseel®.
Collapse
|
23
|
Management of anterior skull base defect depending on its size and location. BIOMED RESEARCH INTERNATIONAL 2014; 2014:346873. [PMID: 24895567 PMCID: PMC4033343 DOI: 10.1155/2014/346873] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/11/2014] [Accepted: 04/13/2014] [Indexed: 11/17/2022]
Abstract
INTRODUCTION We present our experience in the reconstruction of these leaks depending on their size and location. MATERIAL AND METHODS Fifty-four patients who underwent advanced skull base surgery (large defects, >20 mm) and 62 patients with CSF leaks of different origin (small, 2-10 mm, and midsize, 11-20 mm, defects) were included in the retrospective study. Large defects were reconstructed with a nasoseptal pedicled flap positioned on fat and fascia lata. In small and midsized leaks. Fascia lata in an underlay position was used for its reconstruction covered with mucoperiosteum of either the middle or the inferior turbinate. RESULTS The most frequent etiology for small and midsized defects was spontaneous (48.4%), followed by trauma (24.2%), iatrogenic (5%). The success rate after the first surgical reconstruction was 91% and 98% in large skull base defects and small/midsized, respectively. Rescue surgery achieved 100%. CONCLUSIONS Endoscopic surgery for any type of skull base defect is the gold standard. The size of the defects does not seem to play a significant role in the success rate. Fascia lata and mucoperiosteum of the turbinate allow a two-layer reconstruction of small and midsized defects. For larger skull base defects, a combination of fat, fascia lata, and nasoseptal pedicled flaps provides a successful reconstruction.
Collapse
|
24
|
Alobid I, Enseñat J, Rioja E, Enriquez K, Viscovich L, de Notaris M, Bernal-Sprekelsen M. Management of Cerebrospinal Fluid Leaks According to Size. Our Experience. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.otoeng.2014.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
25
|
Alobid I, Enseñat J, Rioja E, Enriquez K, Viscovich L, de Notaris M, Bernal-Sprekelsen M. Manejo de las fístulas nasales de líquido cefalorraquídeo según su tamaño. Nuestra experiencia. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2014; 65:162-9. [DOI: 10.1016/j.otorri.2013.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 11/28/2013] [Accepted: 12/09/2013] [Indexed: 12/01/2022]
|
26
|
Yıldırım AE, Dıvanlıoglu D, Cetinalp NE, Belen AD. Endoscopic endonasal repair of spontaneous sphenoid sinus lateral wall meningocele presenting with cerebrospinal fluid leak. J Neurosci Rural Pract 2014; 5:168-70. [PMID: 24966559 PMCID: PMC4064186 DOI: 10.4103/0976-3147.131668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Spontaneous sphenoid sinus lateral wall meningoceles are rare lesions with an unknown etiology. Endoscopic endonasal technique is a considerable route in the treatment of this condition. The aim of this paper is to report the etiology, surgical technique, and outcome in a patient repaired via endoscopic endonasal approach. A 51-year-old male patient applied with rhinorrhea started three months ago after an upper respiratory infection. There were no history of trauma or sinus operation. Biochemical analysis of the fluid was positive for beta-2-transferrin. This asypthomatic patient had undergone for repairment of lateral sphenoid sinus meningocele with endoscopic endonasal transsphenoidal approach. After endoscopic endonasal meningocele closure procedure no complications occured and a quick recovery was observed. Endoscopic endonasal approach is an effective and safe treatment modality of spontaneous lateral sphenoid sinus meningoceles and efficient in anterior skull base reconstruction.
Collapse
Affiliation(s)
- Ali Erdem Yıldırım
- Department of Neurosurgery, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Denizhan Dıvanlıoglu
- Department of Neurosurgery, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Nuri Eralp Cetinalp
- Department of Neurosurgery, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Ahmed Deniz Belen
- Department of Neurosurgery, Ankara Numune Education and Research Hospital, Ankara, Turkey
| |
Collapse
|
27
|
|
28
|
Abstract
OBJECTIVES To 1) review the existing evidence for early mobilization of the critically ill patients in the ICU with polytrauma; 2) provide intensivists with an introduction to the biomechanics, physiology, and nomenclature of injuries; 3) summarize the evidence for early mobilization in each anatomic area; and 4) provide recommendations for the mobilization of these patients. DATA SOURCES A literature search of the MEDLINE and EMBASE databases for articles published in English between 1980 and 2011. STUDY SELECTION Studies pertaining to physical therapy and rehabilitation in trauma patients were selected. Articles were excluded if they dealt with pediatrics, geriatrics, burn injuries, isolated hand injuries, chronic (i.e., not acute) injuries, nontraumatic conditions, and pressure/decubitus ulcers, were in a language other than English, were published only in abstract form, were letters to the editor, were case reports, or were published prior to 1980. DATA EXTRACTION Reviewers extracted data and summarized results according to anatomical areas. DATA SYNTHESIS Of 1,411 titles and abstracts, 103 met inclusion criteria. We found no articles specifically addressing the rehabilitation of polytrauma patients in the ICU setting or patients with polytrauma in general. We summarized the articles addressing the role of mobilization for specific injuries and treatments. We used this evidence, in combination with biologic rationale and physician and surgeon experience and expertise, to summarize the important considerations when providing physical therapy to these patients in the ICU setting. CONCLUSIONS There is a paucity of evidence addressing the role of early mobilization of ICU patients with polytrauma and patients with polytrauma in general. Evidence for the beneficial role of early mobilization of specific injuries exists. Important considerations when applying a strategy of early physical therapy and mobilization to this distinctive patient group are summarized.
Collapse
|
29
|
Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea. Eur Arch Otorhinolaryngol 2013; 271:1073-9. [PMID: 23982671 DOI: 10.1007/s00405-013-2674-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 08/19/2013] [Indexed: 10/26/2022]
Abstract
The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery. The clear anatomical exposure of the roof of the nasal and paranasal sinus cavities by the endoscope offers the surgeon a golden chance to identify the area of CSF leak, and thus enables one to adequately plan the management. The aim of this work is to evaluate the use of facia lata sandwich graft technique for endoscopic endonasal repair of CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were treated endoscopically using 2 layers of facia lata (underlay and onlay) interposed with a layer of septal cartilage or conchal bone in-between (sandwich technique) for repair. Fifty-five percent of cases were regarded as spontaneous CSF leaks with no obvious cause, 30% following head injury and 15% were iatrogenic. The ethmoidal roof was the commonest location of CSF leak (60%) followed in frequency by the cribriform plate and the sphenoid sinus (20% each). Follow-up period was 12-24 months. We have achieved a 95% success rate in managing CSF leaks in our 40 patients in the first attempt repair and 100% success rate after second attempt repair. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high success rate and avoid the morbidity associated with craniotomy. Using the three-layer, sandwich-grafting technique of facia lata further adds more security to the sealing of CSF and augments the results of repair.
Collapse
|
30
|
Ziu M, Savage JG, Jimenez DF. Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. Neurosurg Focus 2013; 32:E3. [PMID: 22655692 DOI: 10.3171/2012.4.focus1244] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebrospinal fluid rhinorrhea is a serious and potentially fatal condition because of an increased risk of meningitis and brain abscess. Approximately 80% of all cases occur in patients with head injuries and craniofacial fractures. Despite technical advances in the diagnosis and management of CSF rhinorrhea caused by craniofacial injury through the introduction of MRI and endoscopic extracranial surgical approaches, difficulties remain. The authors review here the pathophysiology, diagnosis, and management of CSF rhinorrhea relevant exclusively to traumatic anterior skull base injuries and attempt to identify areas in which further work is needed.
Collapse
Affiliation(s)
- Mateo Ziu
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229-3900, USA.
| | | | | |
Collapse
|
31
|
Yeo NK, Cho GS, Kim CJ, Lim GC, Jang YJ, Lee BJ, Chung YS. The effectiveness of lumbar drainage in the conservative and surgical treatment of traumatic cerebrospinal fluid rhinorrhea. Acta Otolaryngol 2013; 133:82-90. [PMID: 22992063 DOI: 10.3109/00016489.2012.717180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS We found no differences in clinicopathologic factors and post-treatment effects between patients who did and did not receive lumbar drains (LDs) in the management of cerebrospinal fluid (CSF) rhinorrhea. Care should be taken in using LDs, after considering their effectiveness and complications, although routine use of an LD is not indicated in the management of traumatic CSF rhinorrhea. OBJECTIVES We assessed the role and effectiveness of LDs in patients managed conservatively and surgically. METHODS Of 117 patients treated for CSF rhinorrhea, 61 were managed conservatively and 56 were initially managed surgically. We compared the clinicopathologic features and factors related to treatment outcome between patients who did and did not receive LDs. RESULTS Of 61 conservatively managed patients, 32 were managed without and 29 with LDs. There were no between-group differences in any clinicopathologic factors, recurrence rate, or incidence of meningitis during/after treatment, but duration of hospitalization differed significantly (15.3 vs 23.2 days, p = 0.03). Of 56 surgically managed patients, 24 were managed without and 32 with postoperative LDs. Except for age, there were no between-group differences in clinicopathologic factors. In terms of treatment outcome-related factors, there was no significant difference in recurrence rate, incidence of meningitis, or duration of hospitalization.
Collapse
Affiliation(s)
- Nam-Kyung Yeo
- Department of Otolaryngology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | | | | | | | | | | | | |
Collapse
|
32
|
Comparison of gel-based methods for the detection of cerebrospinal fluid rhinorrhea. Clin Chim Acta 2012; 413:1145-50. [PMID: 22483794 DOI: 10.1016/j.cca.2012.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/15/2012] [Accepted: 03/21/2012] [Indexed: 11/21/2022]
Abstract
Cerebrospinal fluid (CSF) rhinorrhea is a serious condition that may result in severe complications. Various laboratory tests, relying on the detection of CSF-specific proteins in nasal secretions, have been developed but diagnosis remains challenging. The aim of this study was to evaluate two new methods targeting either ß2-transferrin or beta-trace-protein. Rhinorrhea samples from patients suspected of CSF leakage (n=36) were analyzed using two-dimensional gel electrophoresis (2-DE) for CSF rhinorrhea diagnosis. Twelve patients with rhinorrhea strongly suggestive of a CSF leak also underwent a fluorescein test. The same cohort was retrospectively analyzed with a beta-trace protein immunoblot developed in-house (n=36) and a new commercial ß2-transferrin immunofixation assay (Sebia, Evry, France) (n=33). 2-DE was positive in 9 patients suffering from rhinorrhea following skull base fracture (n=3), post-surgery (n=4), or spontaneously (n=2). The 27 remaining cases were negative. These results were confirmed by the beta-trace protein immunoblot and ß2-transferrin immunofixation tests, except for one sample found negative with 2-DE but positive with the two other assays. Results from the three analytical methods were concordant with fluorescein tests. Beta-trace protein immunoblot and ß2-transferrin immunofixation assays are fast and reliable methods that allow detecting CSF leakage in nasal fluid with high sensitivity and specificity.
Collapse
|
33
|
Ozturk K, Karabagli H, Bulut S, Egilmez M, Duran M. Is the use of topical fluorescein helpful for management of CSF leakage? Laryngoscope 2012; 122:1215-8. [PMID: 22460742 DOI: 10.1002/lary.23277] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 01/21/2012] [Accepted: 02/10/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS We aimed to evaluate the effectiveness of topical intranasal fluorescence application together with high-resolution computed tomography and magnetic resonance imaging and/or magnetic resonance cisternography for the preoperative diagnosis of cerebrospinal fluid (CSF) leakage and for intraoperative localization of CSF fistulas. We also assessed postoperative recurrence. STUDY DESIGN Descriptive study. METHODS Twenty-four cases underwent endonasal endoscopic repair for CSF leakage. Following intranasal topical application of fluorescein 10% to the middle turbinate-cribriform plate region and anterior wall of the sphenoid sinus, a color change of the fluorescein from yellow-brown to green was accepted as evidence of CSF leakage. A nasoseptal flap, collagen matrix, or fascia lata and septal cartilage graft were used for reconstruction of the CSF fistula. RESULTS The use of topical fluorescein application was helpful in diagnosing CSF rhinorrhea preoperatively and locating the CSF fistula intraoperatively. One case had both ethmoid roof and sphenoid sinus defects, and this case underwent a second operation for closure of the sphenoid defect. All CSF leakages were successfully repaired by endoscopic endonasal surgery using a nasoseptal flap. CONCLUSIONS Cases with traumatic CSF leakage pose a higher risk of meningitis than the cases with spontaneous CSF leakage. Topical application of fluorescein is highly specific and sensitive in identifying preoperative, intraoperative, and postoperative CSF leakage. It is a simple, quick, and sensitive technique. The surgeon should be vigilant for multiple defects.
Collapse
Affiliation(s)
- Kayhan Ozturk
- Department of Otolaryngology, Selcuklu Faculty of Medicine, Selcuk University, Konya, Turkey.
| | | | | | | | | |
Collapse
|
34
|
Occurrence and surgical management of a cerebrospinal fluid-filled cystoid space following routine enucleation. Ophthalmic Plast Reconstr Surg 2012; 28:e117-8. [PMID: 22366667 DOI: 10.1097/iop.0b013e318242ab62] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 73-year-old woman underwent routine enucleation for a blind, painful eye related to end-stage diabetic retinopathy and neovascular glaucoma. A large cystoid space, in continuity with the optic nerve stump, formed around the implant in the first few weeks following surgery. Aspirated contents were positive for β-2 transferrin, confirming cerebrospinal fluid origin. Multiple comorbidities delayed surgical intervention, but the condition was ultimately managed with exposure of the patent optic nerve sheath at the compartment's base, temporary control of cerebrospinal fluid leakage with pulmonary hyperventilation and topical fibrin glue, dissection and vascular-clip ligation of the nerve stump, and capping with a dermis-fat graft. To the authors' knowledge, this postenucleation entity has not been previously described, and asymptomatic idiopathic intracranial hypertension may have been an underlying factor.
Collapse
|
35
|
Abstract
This article discusses the epidemiology, diagnosis, and management of traumatic cerebrospinal fluid (CSF) leaks. An overview of traumatic CSF leaks is presented, and both conservative and operative therapies are reviewed. Management decisions are discussed based on the current literature. Controversial clinical topics are addressed, including the use of prophylactic antibiotics and the timing of surgical repair.
Collapse
|
36
|
Unexpected cerebrospinal fluid rhinorrhea after a spinal anesthesia. J Craniofac Surg 2011; 22:1539-42. [PMID: 21778863 DOI: 10.1097/scs.0b013e31821da355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 47-year-old woman presented with a left-sided watery nasal discharge persisting for 3 weeks after an orthopedic operation using spinal anesthesia. The testing of the nasal fluid for β-2 transferrin confirmed that the leakage was cerebrospinal fluid (CSF). The computed tomographic cisternography revealed a left-sided bone defect in the cribriform plate. Endonasal approach was performed for closing the defect. At 3-month follow-up, CSF rhinorrhea had not recurred. In this report, we present an unexpected CSF rhinorrhea after a spinal anesthesia and discuss the reason of spontaneous leak after spinal anesthesia, as well as discuss current diagnosis and management of CSF rhinorrhea with the composite graft.
Collapse
|
37
|
Ammar H, Meyer MA. A clue in the nose. BMJ Case Rep 2011; 2011:2011/mar01_1/bcr0820103240. [PMID: 22707600 DOI: 10.1136/bcr.08.2010.3240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A morbidly obese 50-year-old woman presented with two episodes of septic meningitis over a 4-month period. The patient admitted having a watery discharge from her right naris for a year; she could not recall a history of head trauma. The glucose level of the discharge was 65 mg/dl. The authors diagnosed cerebrospinal fluid (CSF) rhinorrhoea. A second inspection of the brain CT showed flattening of the pituitary gland suggestive of empty sella, and a right posterior wall sphenoid sinus defect. Our patient had many features suggestive of spontaneous nasal CSF leak. Elevated intracranial pressure is a common finding; it increases the hydrostatic forces exerted at anatomically weakened sites of the skull and eventually produces a bone defect. Endoscopic exploration of the sphenoid sinus showed a bony defect which was repaired. When the patient was last seen 6 months after her surgery, she was doing well and her rhinorrhoea had stopped.
Collapse
Affiliation(s)
- Hussam Ammar
- University at Buffalo, State University at New York, Buffalo, New York, USA.
| | | |
Collapse
|
38
|
Exploration of endonasal endoscopic repair of pediatric cerebrospinal fluid rhinorrhea. Int J Pediatr Otorhinolaryngol 2011; 75:308-15. [PMID: 21145114 DOI: 10.1016/j.ijporl.2010.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 10/23/2010] [Accepted: 11/12/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To summarize the clinical manifestations of pediatric cerebrospinal fluid rhinorrhea (CSFR), discuss the localization of CSFR, and the surgical approaches, the graft material selection and the prognoses of endoscopic repair of CSFR. METHODS The case data, surgical techniques and graft materials of endonasal endoscopic approach of 43 patients with CSFR who have been treated at the Second Xiangya Hospital, Central South University in the last 13 years were retrospectively analyzed. Among them, leaks in 34 cases were from the roof of the ethmoid sinuses. Other sites included frontal sinus (1), sphenoid sinus (6), and the conjunction of ethmoid and frontal sinuses (2). 37 patients were with unilateral CSF leaks, 6 were with bilateral CSF leaks. The dimensions of the defects ranged between 8 and 22mm. For 25 cases, the procedure was as follows: first, the wound surrounding the perimeter of the defect was freshened and the leaks were plugged by myoplasm and overlaid with iliac fascia, and followed by the use of fibrin glue and nasal packing; for 5 cases, the procedure was as follows: at first, the wound was curetted and the leaks were intracranially plugged by autologous cartilage and muscle, overlaid with iliac fascia, followed by the use of fibrin glue and nasal packing; for 6 cases, the leaks were overlaid with iliac fascia only, and then fibrin and packing were used. For the rest of 7 cases, the frontal and sphenoid sinuses were filled with muscle. RESULTS Of the total 43 cases, 31 had successful closure of the leaks by endonasal endoscopic repair on first attempt; 8 had successful closure of the leaks on second attempt, 3 was cured on third attempt; while, leaks in 2 patients failed to close after three attempts. Therefore, they underwent combined intracranial and transnasal endoscopic repair, one patient was cured and another one died postoperatively because of recurrent intracranial infection. At 12 month to 24 month follow-up 42 children remained leak free. CONCLUSION Endoscopic repair of CSF leaks is the optimum approach to the treatment of pediatric CSFR, featuring minor trauma, high successful rate, fewer complications and advantage of being able to carry out a revision surgery or more if needed. For children who have a large CSF leak in size and have failed to be treated successfully via endonasal endoscopic repair, combined intracranial and endoscopic repair could be performed to close the leak.
Collapse
|
39
|
Maguire RC, Gull J, Weaver M, Sataloff RT. Otolaryngologic uses for spinal drains. EAR, NOSE & THROAT JOURNAL 2011; 89:E17-22. [PMID: 20981648 DOI: 10.1177/014556131008901004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cerebrospinal fluid (CSF) fistulae have been encountered by otolaryngologists often since the advent of modern endoscopic sinus surgery, otologic surgery, and skull base surgery. Treatment of CSF leaks may include bed rest, head-of-bed elevation, stool softeners, external spinal fluid drainage, and surgery. External CSF drainage is accomplished via a lumbar spinal drain. Placement of spinal drains is often performed by neurosurgeons and anesthetists. A few otolaryngologists have been trained in the placement and management of lumbar drains, but at most otolaryngology training institutions, education in lumbar drains is not provided. However, in some circumstances, it may fall to an otolaryngologist to accomplish the task. We believe that every otolaryngologist, from the generalist in private practice to the academic neuro-otologic surgeon, should understand the proper technique for the insertion and management of a lumbar drain. Otolaryngologists should be familiar with the physiologic properties of CSF, the methods used to diagnose fistulae, and the techniques used to repair leaks. External spinal drainage is an important element in the management of CSF fistulae, and it has been used in treating perilymphatic fistulae and "gushers." Much controversy surrounds its routine use. Otolaryngologists need to understand the risks, benefits, and outcomes of spinal drain use in order to decide which patients may benefit from this procedure.
Collapse
Affiliation(s)
- Raymond C Maguire
- Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA 19103, USA
| | | | | | | |
Collapse
|
40
|
Cui S, Han D, Zhou B, Zhang L, Li Y, Ge W, Huang Q. Endoscopic endonasal surgery for recurrent cerebrospinal fluid rhinorrhea. Acta Otolaryngol 2010; 130:1169-74. [PMID: 20735181 DOI: 10.3109/00016481003602090] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSIONS CT and MRI are helpful to detect the precise site of the fistula, which is crucial for carrying out the repair, and transnasal endoscopic surgery is an effective treatment for recurrent cerebrospinal fluid (CSF) rhinorrhea. OBJECTIVE To discuss the cause and treatment of recurrent CSF rhinorrhea. METHODS A retrospective study was undertaken to analyze the clinical characteristics of 32 patients with recurrent CSF rhinorrhea. After detailed examination and radiological evaluation by CT and MRI, all of them underwent transnasal endoscopic surgery. RESULTS Six patients presented a leakage at the posterior wall of the frontal sinus, 12 at the ethmoid roof, and 14 at the sphenoid roof. Four cases with a defect in the frontal sinus and frontal recess were repaired with the DRAF III procedure, four cases with a defect in the sphenoid lateral recess were repaired through transpterygoid intervention and under an image-guided navigation system, while the others were operated by routine endoscopic sinus surgery. No recurrence was found during the follow-up for 14-60 months (mean 36.8) in 31 cases, and 1 case with recurrence recovered well after further surgery.
Collapse
Affiliation(s)
- Shunjiu Cui
- Department of Otolaryngology Head and Neck Surgery, Beijing Tong Ren Hospital, Capital Medical University, Ministry of Education, China
| | | | | | | | | | | | | |
Collapse
|
41
|
Tabaee A, Anand VK, Cappabianca P, Stamm A, Esposito F, Schwartz TH. Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus. J Neurosurg 2010; 112:1070-7. [PMID: 19698044 DOI: 10.3171/2009.7.jns0842] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Spontaneous meningoencephaloceles of the lateral sphenoid sinus are rare lesions that are hypothesized to result from persistence of the lateral craniopharyngeal canal. Prior reports of the management of this lesion have been limited by its relative rarity. The objective of this paper is to report the theoretical etiology, surgical technique, and outcomes in patients undergoing endoscopic repair of spontaneous meningoencephalocele of the sphenoid sinus. METHODS The authors conducted a retrospective review of a multiinstitutional series of 13 cases involving patients who underwent endoscopic repair of spontaneous meningoencephalocele of the lateral sphenoid sinus. The surgical technique and pathophysiological considerations are discussed. RESULTS The clinical manifestations included CSF rhinorrhea (85%), chronic headache (77%), and a history of meningitis (15%). The endoscopic approaches to the lateral sphenoid sinus were transnasal (39%), transpterygoid (23%), and transethmoid (39%). Two patients (8%) had postoperative CSF leaks, one of which closed spontaneously and one of which required revision endoscopic closure. All patients were free of leak at most recent follow-up. One patient experienced postoperative meningitis in the early postoperative period. CONCLUSIONS Endoscopic endonasal closure is an effective modality in the treatment of spontaneous meningoencephaloceles of the lateral sphenoid sinus. If the sphenoid sinus has extensive lateral pneumatization, adequate exposure may require a transpterygoid approach.
Collapse
Affiliation(s)
- Abtin Tabaee
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Medical College of Cornell University, New York, New York, USA.
| | | | | | | | | | | |
Collapse
|
42
|
Hsu CCT, Kwan GNC, Bhuta SS. Non-traumatic cerebrospinal fluid rhinorrhea caused by ethmoid sinus osteoma. J Clin Neurosci 2010; 17:1185-6. [PMID: 20493711 DOI: 10.1016/j.jocn.2009.11.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 11/25/2009] [Accepted: 11/29/2009] [Indexed: 11/27/2022]
Abstract
Cerebrospinal fluid (CSF) rhinorrhea is a rare complication of ethmoid sinus osteoma, considering its benign and indolent nature. We present a 36-year-old female patient with symptomatic CSF rhinorrhea as a primary presentation of ethmoid sinus osteoma. We have highlighted the imaging features and emphasised the importance of imaging in the diagnosis of spontaneous CSF leak.
Collapse
Affiliation(s)
- Charlie C-T Hsu
- Bond University, Faculty of Health Sciences and Medicine, Gold Coast, Queensland 4229, Australia
| | | | | |
Collapse
|
43
|
Lahiri U, Labadie RF, Liu C, Balachandran R, Majdani O, Sarkar N. A step toward identification of surgical actions in mastoidectomy. IEEE Trans Biomed Eng 2010; 57:479-87. [PMID: 19770082 PMCID: PMC4843799 DOI: 10.1109/tbme.2009.2031982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mastoidectomy is a core surgical procedure in otologic surgery. It is believed that the procedure is performed by different surgeons with some variability. However, it is also believed that all surgeons use a finite number of fundamental surgical actions to complete the procedure. To determine how a surgeon performs a mastoidectomy, we sought to identify the fundamental surgical actions [called action primitives (APs)] and determine the transition boundaries among those APs. Our motivation for this paper is both to delineate the APs necessary to complete a mastoidectomy and to optimize and potentially automate the surgical process. In this paper, we present a new approach to developing methods for parsing raw data (position and orientation of the surgical tool and end-effector force) into a sequence of surgical tasks. The overall objective is to de-construct the surgical procedure into a series of APs. This paper presents results from our initial investigation on detecting transition boundaries and identifying APs involved in mastoidectomy.
Collapse
Affiliation(s)
- Uttama Lahiri
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235-1592, USA.
| | | | | | | | | | | |
Collapse
|
44
|
Bachar G, Barker E, Chan H, Daly MJ, Nithiananthan S, Vescan A, Irish JC, Siewerdsen JH. Visualization of anterior skull base defects with intraoperative cone-beam CT. Head Neck 2009; 32:504-12. [PMID: 19693942 DOI: 10.1002/hed.21219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The role of cone-beam CT (CBCT) in demonstrating anterior skull base defects (ASBDs), differing in size and location, was investigated. The study was designed to describe the potential advantage of CBCT in the setting of an intraoperative cerebrospinal fluid (CSF) leak. METHODS In all, 120 ASBD were evaluated in 5 cadaver heads. Orthogonal and oblique slices were reconstructed. Observer studies assessed the visibility of ASBD in each location as a function of defect size. RESULTS For 1-, 2-, and 4-mm defects, the percentage that were undetectable ranged from 20% to 33%, 0% to 14%, and 0% to 5%, respectively. Confident breach detection increased with defect size and was most challenging in the lateral lamella and cribriform. CBCT permitted confident detection of ASBD as small as about 2 mm in the fovea ethmoidalis and planum. Oblique views were found to be superior to orthogonal planes. CONCLUSIONS The ability to identify ASBD depended on the size and location of defect. Oblique viewing planes were optimal for ASBD visualization.
Collapse
Affiliation(s)
- Gideon Bachar
- Department of Otolaryngology-Head and Neck Surgery, Department of Surgical Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada.
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Becker SS, Duncavage JA, Russell PT. Endoscopic endonasal repair of difficult-to-access cerebrospinal fluid leaks of the frontal sinus. Am J Rhinol Allergy 2009; 23:181-4. [PMID: 19401046 DOI: 10.2500/ajra.2009.23.3291] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leaks located within the frontal sinus can be difficult to repair effectively. Additional challenges arise from the need to simultaneously repair the leak or defect and to ensure the future patency of the sinus itself. METHODS The cases of two patients who underwent surgical repair of CSF leaks and skull base defects located in difficult to access locations within their frontal sinuses were reviewed. RESULTS Two patients with CSF leaks in the frontal sinus underwent surgery to repair the leaks. The leaks were in the superomedial and superolateral locations within the sinus. One leak (in the superolateral location) was secondary to iatrogenic surgical trauma during craniotomy. The second leak (in the superomedial location) was secondary to congenital encephalocele. Surgical approach to ensure adequate exposure was via endoscopic modified Lothrop procedure. Successful repair was undertaken via underlay technique. At follow-up (27 and 7 months, respectively), frontal sinuses remained patent without evidence of CSF leak. CONCLUSION CSF leaks located in medial and lateral areas of the frontal sinus may be successfully repaired via endonasal approach with endoscopic modified Lothrop. Repair in this manner requires that attention be paid both to achieving a complete repair and to maintaining a patent sinus drainage pathway.
Collapse
Affiliation(s)
- Samuel S Becker
- Department of Otolaryngology and Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee 37232-8605, USA
| | | | | |
Collapse
|
46
|
Klossek JM. Recherche et prise en charge de la porte d’entrée ORL des méningites aiguës bactériennes communautaires. Med Mal Infect 2009; 39:554-9. [DOI: 10.1016/j.medmal.2009.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
|
47
|
Endoscopic repair of cerebrospinal fluid rhinorrhea - Manipal experience. Indian J Otolaryngol Head Neck Surg 2009; 61:14-8. [PMID: 23120596 DOI: 10.1007/s12070-009-0026-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Otolaryngologists play a major role in the management of cerebrospinal fluid (CSF) rhinorrhea. A thorough understanding of the underlying pathophysiology and the various treatment options available is essential to achieve the best possible results.In this paper, we are highlighting the pathophysiology, diagnosis and surgical technique involved in the repair of cerebrospinal fluid rhinorrhea. A retrospective study conducted in the department of ENT and Head and Neck Surgery, Kasturba Hospital, Manipal is presented to highlight our experience with cerebrospinal fluid rhinorrhea.Eleven patients were managed in the department of otolaryngology between 1999 and 2005. Seven had spontaneous CSF rhinorrhea, three were due to trauma and one iatrogenic, following surgery. Commonest anatomic site of leak was the cribriform plate in 4 cases. Other sites included sphenoid [2], lateral lamella [2], fovea ethmoidalis [2] and olfactory groove [1]. Onlay technique was performed in 10 out of 11 patients. Closure was successful in 10 out of 11 cases in the first attempt. One patient underwent revision surgery. Patients were followed up for a period ranging from 3 months to 3 years.CSF rhinorrhea is a potentially fatal condition which requires precise and urgent treatment. The transnasal endoscopic repair of CSF leak has a high success rate with low morbidity when performed by experienced endoscopic sinus surgeons. Our experience in managing this condition is presented.
Collapse
|
48
|
Bleier BS, Palmer JN, Gratton MA, Cohen NA. In vivo laser tissue welding in the rabbit maxillary sinus. ACTA ACUST UNITED AC 2009; 22:625-8. [PMID: 19178803 DOI: 10.2500/ajr.2008.22.3244] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND One of the challenges in the current expansion of endoscopic sinonasal surgery is the ability to adequately reconstruct the skull base. Laser tissue welding (LTW) uses laser energy coupled to a biological solder to produce tissue bonds with burst thresholds exceeding human intracranial pressure. This technology could be used to reduce the rate of postoperative cerebrospinal fluid (CSF) leak. We performed this study to determine whether LTW can create durable tissue bonds in sinonasal mucosa that support normal wound healing and produce minimal collateral thermal injury. METHODS Bilateral maxillary sinus mucosal incisions were made in 20 New Zealand white rabbits and one side was repaired using LTW. Burst pressure thresholds were measured on postoperative days 0, 5, and 15 and were compared with control using a two- way ANOVA and a post hoc Tukey test. Welds were examined histologically for thermal injury, inflammation, and fibroplasia and graded on a 4-point scale by three blinded observers. RESULTS The burst pressures of the LTW group were significantly higher than control on postoperative day 0 (120.85 mm Hg, N = 4, SD = 47.84 versus 7.85 mm Hg, N = 4, SD = 0.78), and day 5 (132.56 mm Hg, N = 8, SD = 24.02 versus 41.7 mm Hg, N = 8, SD = 7.2; p < 0.05). By postoperative day 15 there was no significant difference between LTW (169.64 mm Hg, N = 8, SD = 18.49) and control (160.84 mm Hg, N = 8, SD = 14.16) burst thresholds. There was no evidence of thermal injury to the surrounding tissue in any group as well as no difference between experimental group and control with respect to inflammation or fibroplasia. CONCLUSION This is the first in vivo study showing that LTW is capable of producing tissue bonds exceeding human intracranial pressure with negligible thermal injury in sinonasal tissue. Welding can be performed endoscopically using a fiberoptic cable and may be useful in CSF leak and skull base repair.
Collapse
Affiliation(s)
- Benjamin S Bleier
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104-4206, USA.
| | | | | | | |
Collapse
|
49
|
Ray AM. Halo Sign Is Neither Sensitive Nor Specific For Cerebrospinal Fluid Leak. Ann Emerg Med 2009; 53:288. [DOI: 10.1016/j.annemergmed.2008.06.474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 06/27/2008] [Accepted: 06/27/2008] [Indexed: 11/29/2022]
|
50
|
Jacob AK, Dilger JA, Hebl JR. Status Epilepticus and Intrathecal Fluorescein: Anesthesia Providers Beware. Anesth Analg 2008; 107:229-31. [DOI: 10.1213/ane.0b013e318174dfbe] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|