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Endoscopic management of frontal sinus CSF leaks. Braz J Otorhinolaryngol 2020; 88:576-583. [PMID: 33012703 PMCID: PMC9422493 DOI: 10.1016/j.bjorl.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/27/2020] [Accepted: 08/03/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition. Objective To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach. Methods A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined. Results Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 − 41 months). Conclusion Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.
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Abstract
BACKGROUND To validate the repair of frontal sinus cerebrospinal fluid (CSF) leaks with preservation of frontal sinus drainage pathway (FSDP), independently of the approach used, and to establish the indications and limits of the endoscopic approach. METHODS A retrospective evaluation of patients undergoing surgery for frontal sinus CSF leaks was performed. Demographics, indications for both endoscopic/combined endoscopic and open approaches, complications, methods for maintaining FSDP, and perioperative outcomes were examined. RESULTS Fifty-three patients (average age 45 years) with frontal sinus CSF leaks were treated surgically from 2000 to 2018. All CSF leak repairs were successful at the 1st attempt with a mean follow-up of 76.8 months (range 4-227 months). Etiology was spontaneous (14), traumatic (26), and iatrogenic (13). In 17 patients, a purely endoscopic approach was performed, while an endoscopic endonasal orbital transposition procedure was added in 4 out of this group. In 23 patients, a combined endoscopic and osteoplastic procedure was employed, while in 13 patients a combined craniotomy and endoscopic procedure was performed. All frontal sinuses remained patent except for 2 cranialization patients. CONCLUSION With contemporary endoscopic instrumentation and techniques, endoscopic closure of frontal sinus CSF leaks even in the far superolateral wall is feasible in selected patients. However, the surgeon should consider the option of combining an external approach when required. Preserving the FSDP should be the main aim regardless of the approach.
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Jahanshahi J, Zeinalizadeh M, Reza Mohammadi H, Sadrehosseini SM. Endonasal endoscopic management of frontal sinus cerebrospinal fluid leak. Am J Rhinol Allergy 2018; 31:406-411. [PMID: 29122086 DOI: 10.2500/ajra.2017.31.4478] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A frontal sinus leak is uncommon and is seen in ∼15% of cases of patients with cerebrospinal fluid (CSF) rhinorrhea. Now, endonasal endoscopic techniques have been reported to reconstruct skull base defects in the frontal sinus with a favorable outcome. OBJECTIVE To review our experience in the repair of frontal sinus CSF leaks through an endonasal endoscopic approach. METHODS Twenty-four patients with a frontal sinus leak who underwent endonasal endoscopic repair entered the study. Clinical presentation, location, frontal sinusotomy, graft material, follow-up, and frontal sinus status were evaluated. RESULTS Among >100 cases of surgically repaired CSF rhinorrhea, the frontal sinus was the site of the leak in 24 patients (mean age, 28.9 years; mean follow-up, 22 months). The etiology consisted of spontaneous leak and traumatic leak; whereas patients with skull base reconstruction after removal of tumor were excluded. Surgical approaches included Draf IIb, Draf III, Draf IIa in 20, 3, and 1 patients, respectively. Free autografts as two-layer inlay fat-muscle and onlay fascia lata were used in the majority of patients. A success rate was achieved in 95.83% of the patients. CONCLUSION Endonasal endoscopic repair of a frontal sinus leak was a successful procedure, with a low failure rate and minimal morbidity.
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Affiliation(s)
- Javaneh Jahanshahi
- Department of Otolaryngology Head and Neck Surgery, Hamadan University of Medical Sciences, Hamadan, Iran
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Zhang C, Ding X, Lu Y, Hu L, Hu G. Cerebrospinal fluid rhinorrhoea following transsphenoidal surgery for pituitary adenoma: experience in a Chinese centre. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 37:303-307. [PMID: 28872159 PMCID: PMC5584102 DOI: 10.14639/0392-100x-1086] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 09/21/2016] [Indexed: 11/23/2022]
Abstract
The aim of this study was to elucidate the risk factors for cerebrospinal fluid (CSF) rhinorrhoea following transsphenoidal surgery and discuss its prevention and treatments. We retrospectively reviewed 474 consecutive cases of pituitary adenoma treated with 485 transsphenoidal surgical procedures from January 2008 to December 2011 in our department. We analysed the incidence of intra- and post-operative CSF leakage and outcomes of various repair strategies. Intra-operative CSF leakage was encountered in 85 cases (17.9%), and post-operative CSF rhinorrhoea in 13 cases (2.7%). Seven of the 13 patients with post-operative CSF rhinorrhoea did not experience intra-operative CSF leakage; three of these patients had adrenocorticotropic hormone-secreting adenomas. Of the remaining 6 patients with both intra- and post-operative CSF leakage, 2 were treated for giant invasive prolactinomas, and 2 had previously undergone transsphenoidal surgery. In eight patients, the leak was resolved by lumbar puncture, lumbar external drainage, resting in a semi-reclining position, or other conservative treatment. Two CSF leaks were repaired with gelatine foam and fibrin glue using a transsphenoidal approach, and two with autologous fat graft and sellar floor reconstruction using a transnasal endoscopic approach. After undergoing two transnasal endoscopic repairs, one patient with post-operative CSF rhinorrhoea was successfully treated by further lumbar subarachnoid drainage. In conclusion, procedures using gelatine foam, fibrin glue and autologous fat graft are common and effective techniques for the management of CSF rhinorrhoea after transsphenoidal surgery. When a CSF leak is detected during transsphenoidal surgery, thorough sellar reconstruction and long-term follow-up are necessary.
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Affiliation(s)
- C Zhang
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Pediatric Neurosurgery, Xinahua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - X Ding
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Y Lu
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - L Hu
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - G Hu
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Konuthula N, Khan MN, Del Signore A, Govindaraj S, Shrivastava R, Iloreta AM. A Systematic Review of Secondary Cerebrospinal Fluid Leaks. Am J Rhinol Allergy 2017; 31:48-56. [DOI: 10.2500/ajra.2017.31.4487] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Secondary cerebrospinal leaks (CSF) are leaks that recur after an initial endoscopic repair of CSF leaks. Identification of characteristics that could predict secondary leaks may allow surgeons to plan repairs with the knowledge that these defects are more likely to fail. Objective To identify characteristics that could predict secondary CSF leaks. Methods A search of all studies that reported outcomes after endoscopic repair of CSF leaks was conducted by using medical literature data bases. Studies with the following criteria were included: written in the English language, secondary CSF leaks after primary repair, and assessment of success of fistula repair. Data extracted included the etiology of the leak, site of the leak, reconstructive materials used, and success of the repair. Results Ninety-four studies, from 1988 to 2015, with a total of 3149 primary CSF leaks were included. Sixty-three studies (67%) had a success rate of ≥80%; 77 studies (82%) had secondary leak rates of <40%. For 88 of the 94 studies (94%), the success rate after secondary repair improved to 81.0–100%. Of 48 studies that included leaks of more than one site, the sphenoid was the most common site of leak in 26 studies (55%), the ethmoid was the most common site in 16 studies (34%), and the cribriform was the most common site in 11 studies (23%). Conclusion The rate of secondary CSF leaks was low due to advances in endoscopic repair techniques. Spontaneous and iatrogenic CSF leaks were more likely to recur, especially without adequate control of underlying factors, such as increased intracranial pressure and obesity. Further studies with consistent reporting are required for more definitive conclusions about secondary CSF leaks.
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Affiliation(s)
- Neeraja Konuthula
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Mohemmed N. Khan
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Anthony Del Signore
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
| | - Satish Govindaraj
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Raj Shrivastava
- Department of Neurosurgery—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Alfred M. Iloreta
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
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Lobo BC, Baumanis MM, Nelson RF. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review. Laryngoscope Investig Otolaryngol 2017; 2:215-224. [PMID: 29094066 PMCID: PMC5655559 DOI: 10.1002/lio2.75] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/07/2017] [Accepted: 02/21/2017] [Indexed: 11/18/2022] Open
Abstract
Objectives To review the safety and efficacy of surgical management for spontaneous cerebrospinal fluid (CSF) leaks of the anterior and lateral skull base. Data Sources A systematic review of English articles using MEDLINE. Review Methods Search terms included spontaneous, CSF, cerebrospinal fluid, endoscopic, middle fossa, transmastoid, leak, rhinorrhea. Independent extraction of articles by 3 authors. Results Patients with spontaneous CSF leaks are often obese (average BMI of 38 kg/m2) and female (72%). Many patients also have obstructive sleep apnea (∼45%) and many have elevated intracranial pressure when measured by lumbar puncture. In addition to thinning of the skull base, radiographic studies also demonstrate cortical bone thinning. Endoscopic surgical repair of anterior skull base leaks and middle cranial fossa (MCF) approach for repair of lateral skull base leaks are safe and effective with an average short‐term failure rate of 9% and 6.5%, respectively. Long‐term failure rates are low. One randomized trial failed to show improved success of anterior leak repairs with the use of a lumbar drain (LD) (95% with vs. 92% without; P = 0.2). In a large retrospective cohort of MCF lateral skull base repairs, perioperative LD use was not necessary in >94% of patients. Conclusions Spontaneous CSF leaks are associated with female gender, obesity, increased intracranial hypertension, and obstructive sleep apnea. Endoscopic repair of anterior skull base leaks and MCF or transmastoid approaches for lateral skull base leaks have a high success rate of repair. In most cases, intraoperative placement of lumbar drain did not appear to result in improved success rates for either anterior or lateral skull base leaks. Level of Evidence 2a, Systematic Review.
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Affiliation(s)
- Brian C Lobo
- Head and Neck Institute, Cleveland Clinic Foundation Cleveland Ohio U.S.A
| | - Maraya M Baumanis
- Department of Otolaryngology-Head and Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A
| | - Rick F Nelson
- Department of Otolaryngology-Head and Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A.,Head and Neck Institute, Cleveland Clinic Foundation Cleveland Ohio U.S.A
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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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Endoscopic Endonasal Anterior Skull Base Surgery: A Systematic Review of Complications During the Past 65 Years. World Neurosurg 2016; 95:383-391. [PMID: 26960277 DOI: 10.1016/j.wneu.2015.12.105] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 12/19/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Endoscopic skull base surgery is becoming more popular as an approach to the anterior skull base for tumors and cerebrospinal fluid (CSF) fistulae. It offers the advantages of better cosmesis and improved quality of life after surgery. We reviewed the complication rates reported in the literature. METHODS A literature search was performed in the electronic database Ovid MEDLINE (1950 to August 25, 2015) with the search item "([Anterior] AND Skull base surgery) AND endoscopic." RESULTS We identified 82 relevant studies that included 7460 cases. An average overall complication rate of 17.1% (range 0%-68.0%) and a mortality rate of 0.4% (0%-10.0%) were demonstrated in a total of 82 studies that included 7460 cases. The average CSF leak rate for all studies was 8.9% (0%-40.0%) with meningiomas and clival lesions having the greatest CSF leak rates. The most frequent benign pathology encountered was pituitary adenomas (n = 3720, 49.8% of all cases) and the most frequent malignant tumor was esthesioneuroblastoma (n = 120, 1.6% of all cases). Studies that included only CSF fistula repairs had a lower average total complication rate (12.9%) but a greater rate of meningitis compared with studies that reported mixed pathology (2.4% vs. 1.3%). A trend towards a lower total complication rate with increasing study size was observed. CONCLUSIONS The endoscopic approach is an increasingly accepted technique for anterior skull base tumor surgery and is associated with acceptable complication rates. Increasing experience with this technique can decrease rates of complications.
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Sharma SD, Kumar G, Bal J, Eweiss A. Endoscopic repair of cerebrospinal fluid rhinorrhoea. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 133:187-90. [PMID: 26776882 DOI: 10.1016/j.anorl.2015.05.010] [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: 04/13/2015] [Revised: 05/11/2015] [Accepted: 05/18/2015] [Indexed: 10/22/2022]
Abstract
GOAL The purpose of this review was to look at the success rate of transnasal endoscopic repair of CSF rhinorrhoea and the impact of patient factors, repair techniques and adjuvant treatment. MATERIAL AND METHODS A literature search was performed on PubMed, Medline and Cochrane Central databases, independently by two of the authors, of all studies reporting the outcomes of CSF rhinorrhoea repair, published until the 1st June 2014, using keywords Cerebrospinal fluid leak, CSF leak, CSF fistula, CSF leak or fistula repair, endoscopic sinus surgery or ESS complications. Sixty-seven papers were included for the review. RESULT The repair of CSF rhinorrhoea has rapidly evolved over the past 30 years. Prior to the advent of the endoscopic approach, craniotomy was used for repairs, which carried a variable success rate and morbidity. More recently, there have been several case series and reports that describe various endoscopic methods and materials for repair, with mean success rate of 90% (range: 60-100%). The most common site of CSF leak is the ethmoid roof/cribriform plate region. Traumatic CSF leak, in particular iatrogenic, is still the most common cause. Imaging with CT and MRI remains the gold standard for localisation of CSF leaks. The sphenoid sinus is the most common location for CSF leak repair failure. Lumbar drains and antibiotics are used as adjuvant therapy to endoscopic repair, but their benefits are not clear; intrathecal fluorescein can be used to aid location of CSF leak, but should be reserved for more complex cases. Further work into graft materials used and adjuvant treatment is needed to make any meaningful conclusions about their efficacy. CONCLUSION The literature demonstrates that endoscopic repair of CSF rhinorrhoea is safe and effective, with a very low complication rate. It has almost completely replaced the older open techniques.
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Affiliation(s)
- S D Sharma
- Department of Otorhinolaryngology, Queens Hospital, Rom Valley Way, Romford, RM7 0AG Essex, United Kingdom.
| | - G Kumar
- Department of Otorhinolaryngology, Queens Hospital, Rom Valley Way, Romford, RM7 0AG Essex, United Kingdom.
| | - J Bal
- Department of Otorhinolaryngology, Queens Hospital, Rom Valley Way, Romford, RM7 0AG Essex, United Kingdom.
| | - A Eweiss
- Department of Otorhinolaryngology, Queens Hospital, Rom Valley Way, Romford, RM7 0AG Essex, United Kingdom.
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Panuganti BA, Leach M, Antisdel J. Bilateral meningoencephaloceles with cerebrospinal fluid rhinorrhea after facial advancement in the Crouzon syndrome. ALLERGY & RHINOLOGY 2015; 6:138-42. [PMID: 26302737 PMCID: PMC4541637 DOI: 10.2500/ar.2015.6.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) rhinorrhea and encephaloceles are rare complications of craniofacial advancement procedures performed in patients with craniofacial dysostoses (CD) to address the ramifications of their midface hypoplasia including obstructed nasal airway, exorbitism, and impaired mastication. Surgical repair of this CSF rhinorrhea is complicated by occult elevations in intracranial pressure (ICP), potentially necessitating open, transcranial repair. We report the first case in otolaryngology literature of a patient with Crouzon syndrome with late CSF rhinorrhea and encephalocele formation after previous LeFort III facial advancement surgery. OBJECTIVES Describe the case of a patient with Crouzon syndrome who presented with CSF rhinorrhea and encephaloceles as complications of Le Fort III facial advancement surgery. Review the literature pertaining to the incidence and management of post-operative CSF rhinorrhea and encephaloceles. Analyze issues related to repair of these complications, including occult elevations in ICP, the utility of perioperative CSF shunts, and the importance of considering alternative repair schemes to the traditional endonasal, endoscopic approach. METHODS Review of the literature describing CSF rhinorrhea and encephalocele formation following facial advancement in CD, focusing on management strategies. RESULTS CSF rhinorrhea and encephalocele formation are rare complications of craniofacial advancement procedures. Occult elevations in ICP complicate the prospect of permanent surgical repair, potentially necessitating transcranial repair and the use of CSF shunts. Though no consensus exists regarding the utility of perioperative CSF drains, strong associations exist between elevated ICP and failed surgical repair. Additionally, the anatomic changes in the frontal and ethmoid sinuses after facial advancement present a challenge to endoscopic repair. CONCLUSION Otolaryngologists should be aware of the possibility of occult elevations in ICP and sinonasal anatomic abnormalities when repairing CSF rhinorrhea in patients with CD. Clinicians should consider CSF shunt placement and carefully weigh the advantages of the transcranial approach versus endonasal, endoscopic techniques.
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Affiliation(s)
- Bharat A Panuganti
- Department of Otolaryngology, Head and Neck Surgery, Division of Rhinology and Sinus Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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Tomazic PV, Edlinger S, Gellner V, Koele W, Gerstenberger C, Braun H, Mokry M, Stammberger H. Vivostat®: an autologous fibrin sealant as useful adjunct in endoscopic transnasal CSF-leak repair. Eur Arch Otorhinolaryngol 2014; 272:1423-7. [DOI: 10.1007/s00405-014-3230-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 08/01/2014] [Indexed: 11/30/2022]
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Abstract
Treatment of nasal obstruction with conventional septoplasty is a very common operation in otorhinolaryngology. There are considerable complications that may become even life threatening. We report a rare complication of septoplasty, namely, skull base injury. The possible mechanisms and treatment modality are discussed. Like other similar procedures, prevention of the skull base injury is more important than its treatment. Correct knowledge about anatomy of the region and meticulous manipulation and instrumentation are the most considerable topics.
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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.
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Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2012; 147:196-203. [PMID: 22706995 DOI: 10.1177/0194599812451090] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To provide an up-to-date review of the literature on the safety and efficacy of the endoscopic technique for cerebrospinal (CSF) leak repairs. DATA SOURCES PubMed, Medline/Old Medline, and Cochrane Central databases. REVIEW METHODS Using the above outlined data sources, studies involving the endoscopic repair of CSF leaks were reviewed independently by 2 researchers. Studies included met the following criteria: full-text article written in the English language, at least 5 human patients undergoing purely endoscopic surgical repair of a CSF leak, and documented follow-up. Data extracted included leak etiology, presentation and location, the use of imaging, intrathecal fluorescein, and adjunctive measures as well as the success rate of the repair. RESULTS Fifty-five studies, involving 1778 fistulae repairs, were included for analysis. Spontaneous leaks were most prevalent, with the ethmoid roof and sphenoid the most common sites involved. The overall success rate of repair was high at 90% for primary and 97% for secondary repairs. A low complication rate of less than 0.03% was reported. CONCLUSION The endoscopic repair of CSF fistula is both safe and effective and should be considered the standard of care for most cases. Evidence supporting adjunctive measures such as lumbar drains and antibiotics remains limited despite their common use.
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Affiliation(s)
- Alkis J Psaltis
- Department of Otolaryngology Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Adappa ND, Learned KO, Palmer JN, Newman JG, Lee JYK. Radiographic enhancement of the nasoseptal flap does not predict postoperative cerebrospinal fluid leaks in endoscopic skull base reconstruction. Laryngoscope 2012; 122:1226-34. [PMID: 22566127 DOI: 10.1002/lary.23351] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 03/12/2012] [Accepted: 03/15/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Cerebrospinal fluid (CSF) leaks continue to be the most common postoperative complication in expanded endonasal skull base procedures. Currently, a multilayer closure using a vascularized nasoseptal flap is most commonly performed for large ventral skull base defects in an effort to avoid postoperative CSF leaks. We correlated nasoseptal flap enhancement with postoperative CSF leak rates in a group of skull base reconstruction patients. The nasoseptal flap enhancement was determined by immediate postoperative gadolinium-enhanced magnetic resonance imaging (MRI), which allowed for imaging of the flap's vascular pedicle. Our aim was to identify whether nasoseptal flap enhancement contributed to reduction of postoperative CSF leak rates. STUDY DESIGN Retrospective cohort study. METHODS We reviewed 19 patients who underwent expanded endoscopic resections of skull base lesions of advanced complexity. We calculated the incidence of CSF leaks and measured the presence of nasoseptal flap enhancement. RESULTS Of the 19 patients with immediate postoperative MRIs, three developed postoperative CSF leaks. All three CSF leaks were in cases with enhancing vascular pedicles. In contrast, we had three patients without evidence of flap enhancement, none of whom developed a postoperative CSF leak (Fisher exact test, P = 1.0). CSF leak was associated with posterior fossa lesions (P = .25). Nasoseptal flap enhancement was associated with younger age (P = .15). CONCLUSIONS This retrospective cohort study demonstrates that although the vascularized pedicled nasoseptal flap is effective for closure of expanded endonasal skull base procedures, our experience found the actual enhancement of the flap itself does not appear to effect postoperative CSF leak rates.
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Affiliation(s)
- Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
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Abstract
Spontaneous cerebrospinal fluid rhinorrhea represents a distinct clinic entity that is likely a variant of idiopathic intracranial hypertension (IIH). Patients with spontaneous cerebrospinal fluid (CSF) leaks are generally middle-aged obese women with radiographic evidence of skull base defects, associated meningoencephaloceles, and empty sella syndrome, a common sign of increased intracranial pressure. Significant overlap exists in the characteristics of patients with spontaneous CSF leak and IIH. Endoscopic repair of the CSF fistula is the gold standard treatment for this condition, but emerging evidence supports the reduction of CSF pressure as an important adjuvant treatment in this patient population.
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Affiliation(s)
- Eric W Wang
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 550, Charleston, SC 29403, USA
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Abstract
OBJECTIVE The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base. MATERIALS AND METHODS A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009. RESULTS The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted. CONCLUSIONS Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.
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A management algorithm for cerebrospinal fluid leak associated with anterior skull base fractures: detailed clinical and radiological follow-up. Neurosurg Rev 2011; 35:227-37; discussion 237-8. [DOI: 10.1007/s10143-011-0352-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Revised: 05/03/2011] [Accepted: 05/15/2011] [Indexed: 10/17/2022]
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20
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Held-Ziółkowska M, Szwedowicz P, Gotlib T, Osuch-Wójcikiewicz E, Niemczyk K. [Extracranial reconstruction of postoperative injuries of the anterior skull base and dura mater after resection of sinonasal tumors with extension to anterior skull base structures--case report]. Otolaryngol Pol 2011; 65:126-9. [PMID: 22000262 DOI: 10.1016/s0030-6657(11)70720-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 08/05/2011] [Indexed: 10/16/2022]
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El-Sayed IH, Roediger FC, Goldberg AN, Parsa AT, McDermott MW. Endoscopic reconstruction of skull base defects with the nasal septal flap. Skull Base 2011; 18:385-94. [PMID: 19412408 DOI: 10.1055/s-0028-1096202] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Endoscopic technology is allowing larger resections of the anterior and middle skull base with resultant dural defects. A pedicled nasal septal flap (NSF) based on the posterior nasal septal artery has recently been developed for closure of these defects. We describe our initial experience with the NSF for vascularized coverage of skull base defects. DESIGN Retrospective review. SETTING Tertiary care skull base center. PARTICIPANTS Patients undergoing endoscopic harvest of vascularized pedicled flap for skull base reconstruction. RESULTS Twenty-eight patients had 32 NSFs raised over 14 months for benign (7) or malignant (21) lesions. Surgical defects (mean, 4.95 cm(2)) were intracranial (25) and intradural (20, average defect 1.86 cm(2)) in the anterior (10) and central skull base (6), infratemporal fossa (4), orbit (1), or a combination of sites (9). There were no cases of meningitis or cerebrospinal fluid leak (median follow-up, 8.3 months). Two NSFs were injured intraoperatively and two necrosed postoperatively, both in patients with a prior history of radiation to the nasopharynx (p = 0.013). CONCLUSIONS Prior radiation is a risk factor for necrosis. The NSF is easily harvested endonasally, reliably covers a range of skull base defects, and should be considered the first line closure after expanded endonasal skull base resections.
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Affiliation(s)
- Ivan H El-Sayed
- Otolaryngic Division Minimally Invasive Skull Base Surgery, Department of Otolaryngology, University of California at San Francisco, San Francisco, California
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Ye H, Zuo J, Zhao H, Liu S, An H, Liu Y. Endonasal endoscopic repair of cerebrospinal fluid rhinorrhea in a series of 69 patients. Br J Neurosurg 2011; 24:244-8. [PMID: 20233032 DOI: 10.3109/02688690903572087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We presented our experiences in treatment of Cerebrospinal Fluid (CSF) rhinorrhea with an endoscopic endonasal surgery approach, and showed the severe postoperative complications and failures we experienced, in order to outline some of the characteristic problems that can occur. We performed a retrospective analysis of all of the patients with CSF rhinorrhea. All of the patients were managed with an endonasal endoscopic procedure. Data collected included the site of leakage, the surgical interventions, and the postoperative complications. Sixty-nine patients (33 females and 36 males) were included in this study. All patients underwent an endoscopic repair approach with a multilayer reconstructive technique. The success rates of the first attempt in our study were 89%. Four patients presented with postoperative meningitis and brain abscess and one of these patients died of the brain abscess. Our results indicate that an endoscopic endonasal surgery approach provides a wide, safe, and direct route for treatment of CSF rhinorrhea. The precise location of leakage prior to surgery and proper patient selection, eliminating those with large leakages, are helpful in ensuring a successful endoscopic CSF repair with minimal mortality.
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Affiliation(s)
- Huiping Ye
- West China Hospital, Sichuan University, Department of Otolaryngology Head and Neck Surgery, Chnegdu, 610041 China.
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Romero ADCB, Nora JE, Topczewski TE, Aguiar PHPD, Alobid I, Rodriguéz EF. Cerebrospinal fluid fistula after endoscopic transsphenoidal surgery: experience in a spanish center. ARQUIVOS DE NEURO-PSIQUIATRIA 2010; 68:414-7. [DOI: 10.1590/s0004-282x2010000300017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 09/24/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND: Postoperative cerebrospinal fluid (CSF) fistula is the most serious complication after transsphenoidal surgery. OBJECTIVE: To analyze the incidence of CSF fistula after endoscopic transsphenoidal surgery for tumor removal in sellar region; to discuss associated factors and methods used for sellar closure. METHOD: Retrospective study of 67 patients (73 surgeries) operated via transsphenoidal endoscopy at Hospital Vall D'Hebron and Hospital Clinic of the Universidad de Barcelona, Spain. The data collected included: age, sex, hospitalization stay, suprasellar extension of the lesion, type of tumor, evidence of intraoperative CSF fistula, complications of postoperative CSF fistula, previous surgery and radiotherapy. RESULTS: Six patients (8.2%) had postoperative CSF fistula, and their average hospitalization was 5 days longer with resulting complications: two of whom had pneumoencephalus and two with meningitis. No association was found between the data collected and postoperative CSF fistula. CONCLUSION: The rate of CSF fistula after endoscopic transsphenoidal surgery from the present study is contained within the literature. Unlike other reports, no association between the variables and postoperative CSF fistula was found in this report.
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Overly C. Bitemporal hemianopia arising from a suprasellar craniopharyngioma. ACTA ACUST UNITED AC 2010; 80:621-9. [PMID: 19861217 DOI: 10.1016/j.optm.2009.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 05/24/2009] [Accepted: 06/12/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Craniopharyngiomas are uncommon intracranial tumors that arise from remnants of the embryonic craniopharyngeal duct. Although benign in nature, craniopharyngiomas can contribute to significant morbidity. When located near critical structures such as the optic chiasm, pituitary, and hypothalamus, craniopharyngiomas have the potential to cause severe visual, neurological, and endocrine deficits. CASE REPORT A 61-year-old white man presented for an eye examination, complaining of acute peripheral visual field loss in his left eye. Automated threshold visual field testing found a bitemporal hemianopia with spared fixation in his right eye and split fixation in his left eye. Subsequent neuroimaging found a space-occupying suprasellar lesion that was producing substantial optic chiasm compression. Transsphenoidal resection was used to excise the mass. Histologic examination established the diagnosis of a craniopharyngioma. Postoperative complications included cerebrospinal rhinorrhea, hypertropia, and exotropia. CONCLUSION To facilitate early diagnosis and treatment, eye care professionals should be aware that craniopharyngiomas can present with decreased visual acuity and bitemporal hemianopia. Visual deficits can arise from both the aggressive nature of craniopharyngiomas as well as the therapeutic intervention. Patients treated for craniopharyngiomas are at risk for recurrence and need to be followed up on a long-term basis.
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Affiliation(s)
- Cynthia Overly
- Paye Eye Care Center, S.C., Green Bay, Wisconsin 54304, USA.
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