Application of the Mimic Valsalva Maneuver with the Help of a Saccule in Cerebrospinal Fluid Rhinorrhea Reconstruction Surgery

Bath-plug technique for the endoscopic management of cerebrospinal fluid leaks in children

Importance

The safety and efficacy of the bath-plug technique for the closure of cerebrospinal fluid (CSF) leaks in children remain unknown.

Objective

We undertook this study to ascertain whether the bath-plug technique was safe and effective for the repair of CSF leaks.

Methods

We retrospectively reviewed patients who underwent endoscopic repair of CSF leaks with the fat graft as a plug-in at Beijing Children's Hospital from March 2016 to May 2020. Demographic data, medical history, defect sites and sizes, interventions, and clinical outcomes were analyzed. One representative clinical case was additionally selected to highlight the procedure and the healing process.

Results

A total of 18 pediatric patients were included in this study. The group was composed of 11 boys and seven girls, aged from 5 to 123 months. The etiologies included congenital CSF leaks (n = 9) and head trauma (n = 9). Among all patients, 12 fistulas (66.7%) were located at the cribriform plate area, two (11.1%) at the roof of the ethmoid sinuses, two (11.1%) in the sphenoid sinus, and two (11.1%) at the frontal sinus. The maximum diameters of fistulas ranged from 5 to 20 mm, with a median value of 8 mm. Encephaloceles were identified in 14 (77.8%) patients. No hydrocephalus was recognized. All CSF leaks were successfully repaired with a bath-plug technique. Follow-up ranged from 50 to 70 months. No surgical complications were encountered in any patient.

Interpretation

Bath-plug technique is safe and reliable for the endoscopic management of CSF leaks in children. Meticulous peri-operative preparations are important for pediatric patients.

A Systematic Review of Secondary Cerebrospinal Fluid Leaks

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.