Treatment of cerebrospinal fluid rhinorrhea

A 58-year-Old non-smoking woman with intractable cough and rhinorrhea

Our case highlights an uncommon cause of CSF rhinorrhea. The patient was diagnosed with bacterial meningitis and appropriately treated after which, she developed unilateral rhinorrhea followed by non-productive cough. These symptoms were not responsive to multiple treatment regimens, and eventually imaging revealed a dehiscence in the ethmoid air sinus which was surgically repaired. We also performed a literature review on CSF rhinorrhea and provide insights into its evaluation.

Aspiration of Cerebrospinal Fluid Rhinorrhea as a Cause of Non-resolving Pneumonia

We herein report two cases of cerebrospinal fluid (CSF) rhinorrhea associated with lung infiltrates. One patient presented with symptomatic non-resolving pneumonia, while the other was asymptomatic. In both cases, the lung infiltrates completely resolved when CSF leakage had subsided. Pulmonary involvement in CSF rhinorrhea is under-recognized, and despite being the definitive treatment, surgery for CSF rhinorrhea is typically postponed due to the presence of lung infiltrates. However, meningitis is a serious complication due to a delay in surgical management. Physicians should be made aware that CSF rhinorrhea is a potential cause of intractable lung infiltrates.

Treatment of traumatic cerebrospinal fluid rhinorrhea via extended extradural anterior skull base approach

OBJECTIVE

To describe and assess the repair technique and perioperative management for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture via extradural anterior skull base approach.

METHODS

This was a retrospective review conducted at the Department of Neurosurgery of the Shanghai Tenth People's Hospital from January 2015 to April 2020. Patients with traumatic CSF rhinorrhea resulting from extensive anterior skull base fracture treated surgically via extended extradural anterior skull base approach were included in this study. The data of medical and radiological records, surgical approaches, repair techniques, peritoperative management, surgical outcome and postoperative follow-up were analyzed. Surgical repair techniques were tailored to the condition of associated injuries of the scalp, bony and dura injuries and associated intracranial lesions. Patients were followed up for the outcome of CSF leak and surgical complications. Data were presented as frequency and percent.

RESULTS

Thirty-five patients were included in this series. The patients' mean age was 33 years (range 11-71 years). Eight patients were treated surgically within 2 weeks; while the other 27 patients, with prolonged or recurrent CSF rhinorrhea, received the repair surgery at 17 days to 10 years after the initial trauma. The mean overall length of follow-up was 23 months (range 3-65 months). All the patients suffered from frontobasal multiple fractures. The basic repair tenet was to achieve watertight seal of the dura. The frontal pericranial flap alone was used in 20 patients, combined with temporalis muscle and/or its facia in 10 patients. Free fascia lata graft was used instead in the rest 5 patients. No CSF leak was found in all the patients at discharge. There was no surgical mortality in this series. Bilateral anosmia was the most common complication. At follow-up, no recurrent CSF leak or meningitis occurred. No patients developed mucoceles, epidural abscess or osteomyelitis. One patient ultimately required ventriculoperitoneal shunt because of progressive hydrocephalus.

CONCLUSION

Traumatic CSF rhinorrhea associated with extensive anterior skull base fractures often requires aggressive treatment via extended intracranial extradural approach. Vascularized tissue flaps are ideal grafts for cranial base reconstruction, either alone or in combination with temporalis muscle and its fascia---fascia lata sometimes can be opted as free autologous graft. The approach is usually reserved for patients with traumatic CSF rhinorrhea in complex frontobasal injuries.

Spontaneous Cerebral Spinal Fluid Rhinorrhea with Meningocele Secondary to Congenital Foramen Rotundum Defect: A Case Report and Review of Literature

Spontaneous cerebrospinal fluid (CSF) rhinorrhea is a rare occurrence. We present a case of spontaneous CSF rhinorrhea in a 57-year-old patient secondary to a sphenoid osseous defect involving the foramen rotundum and maxillary nerve with an associated arachnoid cyst and meningocele compressing the maxillary nerve. The location of the defect made correction amenable to an open skull-based approach. To the best of our knowledge, this is the first reported case of a spontaneous meningocele herniating into the sphenoid osseous defect through the medial aspect of the foramen rotundum. Early detection of these defects, open or endoscopic approaches and definitive treatment by closing the defect can result in excellent outcomes.

Osseous Repair in Minimally Invasive Reconstruction of Anterior Skull Base Defects

Management of anterior skull base defects is an area of continued innovation for skull base surgeons. Various grafting materials have been advocated for the repair of skull base defects depending on needs, availability, harvest site morbidity, and surgeon preference. Spontaneous bony closure of small skull defects is known to occur in animal models without bone grafts, but this phenomenon has been unexplored in the human skull base. The objective of this study was to evaluate osseous skull base closure in patients undergoing endoscopic repair of skull base defects. A retrospective review was performed on 13 patients who underwent endoscopic repair of skull base defects with free bone grafts who were followed with postoperative computed tomography scans. This cohort was compared to postoperative radiology from patients undergoing transsphenoidal surgery without rigid reconstruction to evaluate for spontaneous osseous closure of sellar defects. Free bone grafts are incorporated into the bony skull base in the majority of patients (84.6% with at least partial incorporation) at mean of 5.3 years postoperatively. By comparison, patients undergoing pituitary surgery did not demonstrate spontaneous osseous closure on postoperative imaging. Human anterior skull base defects do not appear to spontaneously close, even when small, suggesting that there is no "critical size defect" in the human skull base, in contrast to the robust wound healing in animal models of skull convexity and mandibular defects. Free bone grafts incorporate into the skull base over the long-term and may be utilized whenever a rigid skull base reconstruction is desired, regardless of the defect size.

An Analysis of Patients Treated for Cerebrospinal Fluid Rhinorrhea in the United States from 2002 to 2010

Background The Nationwide Inpatient Sample (NIS) database was used to analyze the demographic features and concomitant diagnoses in patients admitted with cerebrospinal fluid (CSF) rhinorrhea. Methods We analyzed the NIS database for all hospital admissions of CSF rhinorrhea between 2002 and 2010. Patient demographics, length of stay, hospital charges, concomitant diagnoses, hospital level characteristics, and complications were analyzed for patients undergoing surgical repair (group I) and for those treated without surgical repair (group II). Results Patients in group I were significantly older, the majority were female (67.5%), and were more likely to be obese (12.9%), have diabetes mellitus (15.7%), and hypertension (41.6%). Lengths of stay were similar between the two groups, but group I patients incurred higher hospital charges (p < 0.001). Group I patients were more likely classified as an elective admission (59.8 vs. 38.6%), and were more frequently admitted to a teaching hospital (83.6%) with a large bed size (79.0%). Acute medical complications and concomitant diagnosis of meningitis were similar in both groups. Conclusion Rates of meningitis did not differ between the two groups. Patients who underwent surgical repair were more likely to be an elective admission and admitted to a teaching hospital. Hospital charges were higher in patients undergoing repair.

Endoscopic Endonasal Repair of Spontaneous and Traumatic Cerebrospinal Fluid Rhinorrhea: A Review and Local Experience

This article presents an overview of endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea. In recent years, endoscopic repair has become the standard of care for managing this condition, because it gradually replaces the traditional open transcranial approach. Discussion includes the etiologic classification of CSF rhinorrhea, management paradigm for each category, diagnosis algorithm, comprehensive description of the surgical technique, and an updated review of the literature regarding the safety and efficacy of this procedure. In addition, the authors present their experience, including 2 surgical videos demonstrating endoscopic repair of CSF rhinorrhea in 2 distinct clinical scenarios.