Ascending meningitis secondary to traumatic cerebrospinal fluid leaks

Traumatic CSF rhinorrhea associated with COVID-19 testing: a case series and systematic review

BACKGROUND

This report analyzes traumatic anterior skull base CSF leaks following nasopharyngeal swab testing for detection of SARS-CoV-2 in the largest case series to date, combined with a systematic literature review.

METHODS

Retrospective multi-institutional case-series of traumatic anterior skull base CSF leak with clear antecedent history of COVID-19 swab was completed. A comprehensive search of databases was performed for the systematic literature review.

RESULTS

Thirty-four patients with traumatic CSF leak after COVID-19 nasopharyngeal swab testing were identified. Women were more than twice as likely to experience a CSF leak, as compared to men. The majority of patients (58.8%) had no reported predisposing factor in their clinical history. Common defect sites included the cribriform plate (52.9%), sphenoid sinus (29.4%), and ethmoid roof (17.6%). Four patients (11.8%) presented with meningitis. The median time between the traumatic COVID swab and the detection of CSF leak was 4 weeks (IQR 1-9). Patients with meningitis had a median leak duration of 12 weeks (IQR 8-18). The average leak duration was significantly longer in patients with meningitis compared to without meningitis (p = 0.029), with a moderate effect size (r = - 0.68). Most cases (92.9%) managed with endoscopic endonasal surgical repair were successful.

CONCLUSIONS

This report clarifies the presentation, risk factors, and management of CSF leaks attributable to diagnostic nasopharynx swabbing procedures in the COVID-19 era. Timely surgical repair is the recommended management option for such leaks.

Development and Clinical Validation of a Hook Effect-Based Lateral Flow Immunoassay Sensor for Cerebrospinal Fluid Leak Detection

BACKGROUND AND OBJECTIVES

Rapid detection of cerebrospinal fluid (CSF) leaks is vital for patient recovery after spinal surgery. However, distinguishing CSF-specific transferrin (TF) from serum TF using lateral flow immunoassays (LFI) is challenging due to their structural similarities. This study aims to develop a novel point-of-care diagnostic assay for precise CSF leak detection by quantifying total TF in both CSF and serum.

METHODS

Capitalizing on the substantial 100-fold difference in TF concentrations between CSF and serum, we designed a diagnostic platform based on the well-known "hook effect" resulting from excessive analyte presence. Clinical samples from 37 patients were meticulously tested using the novel LFI sensor, alongside immunofixation as a reference standard.

RESULTS

The hook effect-based LFI sensor exhibited outstanding performance, successfully discriminating positive clinical CSF samples from negative ones with remarkable statistical significance (positive vs negative t -test; P = 1.36E-05). This novel sensor achieved an impressive 100% sensitivity and 100% specificity in CSF leak detection, demonstrating its robust diagnostic capabilities.

CONCLUSION

In conclusion, our study introduces a rapid, highly specific, and sensitive point-of-care test for CSF leak detection, harnessing the distinctive TF concentration profile in CSF compared with serum. This novel hook effect-based LFI sensor holds great promise for improving patient outcomes in the context of spinal surgery and postsurgical recovery. Its ease of use and reliability make it a valuable tool in clinical practice, ensuring timely and accurate CSF leak detection to enhance patient care.

Cut-off value for β-trace protein (β-TP) as a rapid diagnostic of cerebrospinal fluid (CSF) leak detection

Objective

To find an adequate cut-off point for beta trace protein (β-TP) in nasal secretion (NS) and validate this diagnostic test with a large sample of patients. Likewise, we evaluated β-TP test efficacy to confirm the cerebrospinal fluid (CSF) leakage closure after treatment.

Methods

We performed a retrospective analysis with 207 samples from 162 patients with suspected CSF leakage received in the Hospital Universitario Virgen de la Arrixaca between 2010 and 2016. Twenty-five samples were included in the control group. Samples were obtained from NS through a swab to determine β-TP using a nephelometry-based assay. Sensitivity, specificity, and area under the curve (AUC) for β-TP in NS were assessed using the receiver operator characteristic (ROC) analysis.

Results

Using imaging techniques, the diagnosis of CSF leak was confirmed in 57 patients (35.19%), while 105 had a negative diagnosis (64.81%). Patients with CSF leakage had significantly higher β-TP values in NS (16.07 ± 16.94 mg/L, p < .001) than the control group (0.33 ± 0.12 mg/L) and patients without CSF leakage (0.61 ± 2.34 mg/L). Applying a 1 mg/L cut-off point resulted in 96.5% sensitivity and 97.1% specificity. Positive and negative predictive values (PPV and NPV) at this cut-off were 94.9% and 98.6%, respectively. Finally, this cut-off point yields a test efficacy for CSF leak diagnosis of 97% (95% CI 92.9-98.9).

Conclusion

Our study has established a 1 mg/L β-TP concentration in NS as a cut-off point for CSF leakage diagnosis with high sensibility and specificity. These results suggest that β-TP analysis could be useful to check CSF leak resolution.

Level of Evidence

4.

Successful resection of delayed management rupture midline encephalocele: A case report

INTRODUCTION AND IMPORTANCE

Encephalocele is an NTD that affects one in every 10,000 live births. A ruptured encephalocele is advised to be operated on as soon as possible, preferably within 48 h. Signs and symptoms of infection should be considered when performing corrective surgery.

CASE PRESENTATION

We present the case of an 8-day-old baby who had a ruptured midline frontoparietal encephalocele as a result of delayed corrective surgery. The mass on the patient's head measured approximately 7 × 6 × 5 cm with a leakage of clear and yellowish fluids. The head CT scan revealed a multi-enhancement mass, pedunculated with an ill-defined border protruding from the anterior fontanelle.

CLINICAL DISCUSSION

The patient underwent an emergency corrective surgery. Excision was performed completely. The defect was covered with a double-layer closure technique in a watertight manner. The patient's postoperative recovery was uneventful.

CONCLUSION

An encephalocele can only be resolved through corrective surgery. In our case, the ruptured midline encephalocele was easily resolved with an emergency corrective surgery. Closure of the defect soon after birth is advised, especially if no layer of skin protects the encephalocele.

Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review

Cerebrospinal fluid leak (CSFL) is a rare pathological condition which requires prompt and adequate management due to the high rate of associated major complications. At present, CSFL can be successfully treated through endoscopic endonasal approaches with success rates higher than 90%. Despite this, CSFL recurrence may occur, and its management is critical and still represents a matter of debate. A systematic review of the literature on the management of recurrent CSFL was conducted. It included a cohort of 1,083 cases of CSFL treated with surgical or conservative approaches; 112 cases of recurrence were reported for an overall recurrence rate of 10.3%. Most of the leaks were localised in the anterior skull base (68.3%) and identification of recurrent CSFL may be troublesome. Therefore, the entire skull base must be meticulously examined and long-term follow-up is mandatory. The risk for CSFL recurrence is higher in patients affected by idiopathic intracranial hypertension (IIH), but its role in CSFL recurrence is yet to be understood. Recurrent CSFL must be repaired as soon as possible in order to reduce the risk of intracranial complications. The use of early post-operative CSF diversion by lumbar drain (LD) is currently a matter of debate even in case of CSFL recurrences.

Long-Term Follow-up of Patients Managed Conservatively for Acute Traumatic CSF Rhinorrhea

OBJECTIVE

Conservative management of acute traumatic cerebrospinal fluid rhinorrhea (TCR) results in cessation of the leak in most patients. The objective of this study was to estimate the incidence of recurrent cerebrospinal fluid (CSF) rhinorrhea and meningitis in these patients on long-term follow-up and to determine the risk factors associated with them.

METHODS

Data on 50 patients with acute TCR who were successfully treated with conservative management between 2013 and 2015 and had long-term follow-up was retrieved from our head injury database. Patient variables were analyzed to determine the risk factors associated with recurrence of CSF rhinorrhea and meningitis.

RESULTS

All patients in our series developed CSF rhinorrhea within 48 hours of trauma. The mean duration of follow-up was 6.3 ± 1.3 years. CSF rhinorrhea recurred in 16 (32%) patients, 15 (93.8%) of whom developed it within 3 years of trauma. Meningitis occurred in 5 (10%) patients and 1 died. Sphenoid sinus fractures and features of raised intracranial pressure on computerized tomography of the brain at admission were significantly associated with the development of meningitis. There were no risk factors identified for the recurrence of CSF rhinorrhea.

CONCLUSIONS

Patients with acute TCR in whom rhinorrhea subsides with conservative therapy have the highest risk for recurrence of leak or meningitis within 3 years of the trauma. Therefore, we recommend that these patients be counselled about the need for periodic follow-up for several years.

Pediatric Minor Traumatic Brain Injury : Growing Skull Fracture, Traumatic Cerebrospinal Fluid Leakage, Concussion

Traumatic brain injury (TBI) is a major public health issue that causes significant morbidity and mortality in the pediatric population. Pediatric minor TBIs are the most common and are widely underreported because not all patients seek medical attention. The specific management of these patients is distinct from that of adult patients because of the different physiologies in these age groups. This article focuses on minor TBIs, particularly growing skull fractures, traumatic cerebrospinal fluid leakage, and concussion.

Cerebrospinal Fluid Leaks After Anterior Skull Base Trauma: A Systematic Review of the Literature

BACKGROUND

Anterior skull base (ASB) fractures are reported in 4% of head injuries and represent 21% of all skull fractures. Cerebrospinal fluid (CSF) leaks may follow, severely exacerbating outcomes. We systematically reviewed the literature to analyze and compare the roles of endoscopic surgery, open surgery, and combined approaches in the management of CSF leak repair after posttraumatic ASB fractures.

METHODS

PubMed, Web of Science, and Scopus databases were searched in accordance with the PRISMA guidelines. Studies reporting clinical data of patients with CSF leaks after ASB fracture were reviewed, focusing on management strategies and posttreatment outcomes.

RESULTS

We included 29 articles comprising 888 patients. The average age at diagnosis was 34 years (range, 18-91 years), with a male predominance (54%) and a male/female ratio of 2.9:1 (647:241). Clinical data were available for 888 patients with CSF leaks after ASB fracture, reporting a median follow-up time of 33.5 months (standard deviation, ±29; range, 0.5-330.0 months). Open surgical repair was the most common approach (67.9%), followed by endoscopic surgical repair (32.1%). The endoscopy cohort showed lower rates of complications (0.7% vs. 11.1%) and fistula recurrence (2.8% vs. 5.3%) compared with open surgery.

CONCLUSIONS

ASB fractures are frequently treated as late surgery, 24 hours from injury or later, especially for endoscopic surgery. Overall, the endoscopic approach is preferred, mostly because of its safety and effectiveness, offering lower failure rates than does open surgery.

Use of Dental Bisphenol A-Glycidyl Methacrylate Composite to Repair Refractory Cerebrospinal Fluid Leaks Associated With Large-Scale Anterior Skull Base Defects

ABSTRACT

Treatment of refractory cerebrospinal fluid (CSF) leaks, particularly those associated with large skull base defects, is challenging. A variety of synthetic biomaterial-based systems have been investigated in experimental models and/or humans for reconstructing cranial base defects. A widely used dental composite (bisphenol A-glycidyl methacrylate [bis-GMA]) has been shown to be effective for reconstruction of anterior skull base defects in animal models. Here, we report 4 patients who underwent reconstruction of large anterior skull base defects (1405.8 ± 511 mm2) secondary to tumor resection and traumatic injury using the dental bis-GMA resin-based composite. A vascularized pericranial flap with fibrin glue was initially performed in all patients with concurrent use of dental bis-GMA during the primary surgery in 2 patients, and later use (in a repeat surgery) in other 2 cases. In these latter 2, CSF rhinorrhea persisted after the initial surgery (in the absence of bis-GMA use) despite external CSF drainage with lumbar drain. Following treatment with bis-GMA, rigid structural support and watertight closure of the defect were successfully achieved. At the follow-up, CSF leak did not recur and none of the patients had any complications related to the surgery or the composite. The results obtained from this series are promising, and dental bis-GMA resin seems to provide an effective and feasible material for the treatment and prevention of CSF leaks related to large-scale anterior skull base defects. However, further studies with longer clinical follow-up and larger number of patients are required to prove the safety and efficacy of this matrix in the long run.

Anterior Skull Base Surgery via Endoscopic Endonasal Approach: Outcomes and Analysis

BACKGROUND

This study was retrospectively conducted to evaluate the postoperative surgical results of our patients with anterior skull base mass, defect, and/or cerebrospinal fluid rhinorrhea who underwent reconstruction via endoscopic endonasal approach and to share our experiences.

METHODS

Sociodemographic features of patients who had undergone endoscopic surgery in our clinic due to anterior skull base mass, defect, or rhinorrhea were evaluated in terms of etiological factors, surgical method, pathology, postoperative complications, need for revision surgery and comorbid disease.

RESULTS

A total of 131 patients were included; 76 were male and mean age was 36.2 years. Endoscopic endonasal surgery was performed for nasal mass (70.2%) in 92 cases, rhinorrhea (17.6%) in 23 cases, chronic sinusitis (7.6%) in 10 cases, and gunshot injury (4.6%) in 6 cases. After surgery, benign mass pathology was detected in 75 patients and malignant mass pathology was detected in 23 patients. Osteoma was the most common among benign formations, and squamous cell carcinoma was the most common among malignant formations. The most common cause of surgical revision was nasal masses (25 cases, 77.4%).

CONCLUSION

Endoscopic intracranial interventions and increased anterior skull base surgery are garnering increased interest of physicians as endoscopic approaches are gaining popularity in recent years. Successful results are achieved through appropriate diagnostic methods and endoscopic approaches. Success rates will be further increased due to developing technology and imaging methods, while the risk of complications and revision surgery will be further reduced.

Rubber Bullet Induced Traumatic Brain Injury

ABSTRACT

Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

Modern endoscopic skull base neurosurgery

INTRODUCTION

Since the early use of the endoscopic view for treating simple intrasellar pituitary adenomas, the skull base surgery has experienced an unprecedented revolution elevating the treatment of skull base lesions to the next level in proficiency and excellence of care.

METHODS

We have reviewed the preclinical and clinical evidence supporting the use of the endoscope in the treatment of skull base lesions. In this article, we aim to discuss and provide a wide view of the current indications and future perspectives of the endoscopic endonasal approaches (EEA) and of the endoscopic transcranial approaches.

RESULTS

As in the development of any other technique, EEA have gone through a transformation process from theoretical anatomic models to a pragmatic clinical use. Along the way, EEA have required several modifications, as well as pushbacks in the application of this technique in some indications. This process has resulted in the provision of an additional tool to the current surgical armamentarium that allows the skull base surgeon to face most challenging lesions along the skull base.

CONCLUSIONS

The judicious combination of transcranial and endoscopic-transnasal approaches warrants highest chances of achieving satisfactory tumors resection with a reduced risk of complications.

Our Experience on Temporal Bone Fractures: Retrospective Analysis of 141 Cases

Temporal bone fractures are a common lesion of the base of the skull. The diagnosis and management of temporal bone fractures require a multidisciplinary approach. Variable clinical presentations may arise from such fractures, ranging from an asymptomatic course to very serious consequences. The aim of this study was to report our experience with a series of patients with temporal bone fractures and to propose a diagnostic/therapeutic algorithm. This study enrolled 141 patients, 96 (68.1%) males and 45 (31.9%) females, ranging in age from 20 to 60 (average age: 39 ± 4.1 years), with temporal bone fractures who were referred to Cardarelli Hospital between 2006 and 2018. The present paper presents a classification of temporal bone fractures and typical clinical sequelae and provides an illustration of their prognosis and treatment.

Endoscopic Skull Base Repair Strategy for CSF Leaks Associated with Pneumocephalus

Background: Cerebrospinal (CSF) fluid leaks with associated pneumocephalus (PNC) represent a condition bearing serious risks for the patient, with little data available in the literature. Reported success rates of endoscopic skull base repair are lower when PNC is associated than in the case of simple CSF leaks. The present study represents an analysis of our experience with endoscopic management of this condition. Methods: Records of patients with pneumocephalus and associated CSF leaks, who underwent endoscopic skull base repair, were reviewed. Demographics, history, etiology of PNC, size of defect, surgical approach, reconstruction technique and complications were evaluated. Results: Twenty patients with CSF leaks and PNC underwent endonasal repair by the senior author between 2005 and 2019. Defect size was larger than 15 mm in all cases. All patients presented either worsening of PNC under conservative treatment or tension PNC. First-attempt closure of the defect was successful in all patients (100%), with resolution of the pneumocephalus. One patient developed a synechia in the proximity of the frontal ostium, as a postoperative complication. The mean follow-up was 39 months (range: 15–94 months). Conclusion: The present study represents a proposed argument for earlier endoscopic endonasal treatment in patients presenting CSF leaks and pneumocephalus.

The association of Le Fort midfacial fractures with frontobasal injuries: a 17-year review of 125 cases, reflections on biomechanics, classifications and treatment

The frequency of midface and frontobasal fractures has increased over the past 40 years despite the improvement and stringent regulation implemented on modern safety equipment (belts, helmets…). This observation might be correlated with the progress of radiodiagnosis tools. Literature was reviewed according to Prisma guidelines. We searched for reviewed articles, published between January 2000 and December 2017, through Medline (Pubmed) online databases and ScienceDirect, using the following MeSH Keywords: "Le Fort classification", "Le Fort fracture", "Frontobasal fracture", "skull base fracture", "Midface Fractures". Among 652 patients with frontobasal fractures, 125 (19.1%) were associated with a Le Fort fracture. 59 (9%) were associated with Le Fort III fracture, 51 (7.8%) with Le Fort II fracture and 15 (2.3%) with Le Fort I fracture. When frontobasal fractures were associated with midfacial fractures, we found 18 cerebrospinal fluid leaks (11.8 %) and 19 cases of meningitis (12.5 %). When only the frontobasal area was involved, there were 6 cerebrospinal fluid leaks (4.3 %) and 6 meningitis (4.3 %). Our results highlight a regular association between Le Fort fractures and frontobasal fractures for stages II and stage III of Le Fort fractures and also found a higher rate of neuro-septic complication. Further research shall investigate treatment and monitoring recommendations fitting modern epidemiology of craniofacial traumatology.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Olfactory Fossa and New Angle Measurements: Lateral Lamella-Cribriform Plate Angle

OBJECTIVES

The authors investigated the olfactory fossa (OF) in patients with unilateral nasal septal deviation (NSD) and presented the lateral lamella-cribriform plate angle (LLCPA).

METHODS

Paranasal sinus computed tomography images of 300 adult subjects with unilateral NSD (111 males, 189 females) were evaluated retrospectively. Septal deviation angle (SDA), Keros Classification, OF depth and width, LLCPA; and orbital plate and cribriform plate (OPCP) distance were measured.

RESULTS

The OF depth values (ipsilateral, contralateral) were found as Keros III >Keros II >Keros I (Padjusted <0.0175). The OF width values (ipsilateral) were detected as Keros I >Keros II and Keros I >Keros III (Padjusted <0.0175). In patients with higher SDA values, ipsilateral OF depth values decreased (P <0.05). The LLCPA and OPCP values were higher in Keros I and lower in Keros III (P <0.05).

CONCLUSION

In patients with lower LLCPA and OPCP, endoscopic sinus surgery will be more dangerous for trauma to lateral lamella and intracranial penetration.

Endoscopic Surgical Repair of a Giant, Postoperative, Neglected Meningoencephalocele

Meningoencephalocele is a rare and potentially lethal disease, requiring early diagnosis and treatment. A 30-year-old male patient was diagnosed with a massive meningoencephalocele. His medical history included cerebrospinal fluid (CSF) rhinorrhea since the age of 7 years, which was attributed to right eye mining during infancy due to Coats disease. Following failed attempts of open surgical repair and CSF diversion during childhood, no further attempts of surgical management were made. He presented a long history of recurrent episodes of meningitis, resulting in long-lasting hospitalization in the intensive care unit. Eventually, he underwent surgical repair through an endoscopic multilayer approach. Subsequent endoscopic and radiological assessment demonstrated no recurrence during a follow-up period of one year. Endoscopic treatment is highly successful. An effective and definite surgical repair is of paramount importance in order to avoid life-threatening complications, improve patient’s and caregiver’s quality of life, and avoid unnecessary health-system costs.

Pseudo-Cerebrospinal Fluid Leaks of the Anterior Skull Base: Algorithm for Diagnosis and Management

Objective  Pseudo-cerebrospinal fluid (CSF) leaks are a rare cause of unilateral, watery rhinorrhea. We proposed a step-wise approach to evaluate these cases. Design  It involves a single-center retrospective cohort study. Setting  The setting is that of a tertiary academic medical center. Participants  Ten patients with diagnosis of pseudo-CSF leak over a 21-year period were evaluated using our proposed algorithm that includes computed tomography, magnetic resonance imaging, nasal endoscopy, β-2 transferrin, intrathecal fluorescein, and surgical exploration of the anterior cranial base. Main Outcome Measures  The occurrence of intracranial infection and resolution of the symptoms were evaluated at a mean follow-up of 94.4 months. Results  Eight patients had history of skull base fracture or surgery. In all patients computed tomography, magnetic resonance imaging, and nasal endoscopy did not show signs of CSF leak. Beta-2 transferrin testing was performed in five patients, being negative in all of them. Intrathecal fluorescein was performed in seven patients, being negative in five and inconclusive in two. Surgical exploration was performed in five patients, definitively ruling out CSF leak. Six patients were treated with intranasal ipratropium, resolving the symptoms in all cases. Conclusion  The presented algorithm provides a step-wise approach for patients with unilateral watery rhinorrhea, allowing to safely ruling out CSF leak.

Rapid Diagnostic Test Kit for Point-of-Care Cerebrospinal Fluid Leak Detection

Cerebrospinal fluid (CSF) leaks can occur when there is communication between the intracranial cavities and the external environment. They are a common and serious complication of numerous procedures in otolaryngology, and if not treated, persistent leaks can increase a patient's risk of developing life-threatening complications such as meningitis. As it is not uncommon for patients to exhibit increased secretions postoperatively, distinguishing normal secretions from those containing CSF can be difficult. Currently, there are no proven, available tests that allow a medical provider concerned about a CSF leak to inexpensively, rapidly, and noninvasively rule out the presence of a leak. The gold standard laboratory-based test requires that a sample be sent to a tertiary site for analysis, where days to weeks may pass before results return. To address this, our group recently developed a semiquantitative, barcode-style lateral-flow immunoassay (LFA) for the quantification of the beta-trace protein, which has been reported to be an indicator of the presence of CSF leaks. In the work presented here, we created a rapid diagnostic test kit composed of our LFA, a collection swab, dilution buffers, disposable pipettes, and instructions. Validation studies demonstrated excellent predictive capabilities of this kit in distinguishing between clinical specimens containing CSF and those that did not. Our diagnostic kit for CSF leak detection can be operated by an untrained user, does not require any external equipment, and can be performed in approximately 20 min, making it well suited for use at the point of care. This kit has the potential to transform patient outcomes.

Endoscopic Paramedian Forehead Flap Reconstruction of the Anterior Skull Base for Recalcitrant Cerebrospinal Fluid Leaks: Minimally Invasive Adaptation of Ancient Flap

BACKGROUND

The anterior skull base (ASB) remains one of the greatest challenges for reconstructive surgeons. The current armamentarium includes endoscopic placement of free grafts, endonasal vascularized pedicled flaps, regional flaps, and microvascular free flaps. As the defect size increases, reconstruction complexity increases along with potential complications. Here, we report an endoscopic-assisted paramedian forehead flap, a novel adaptation of an age-old technique, for ASB reconstruction.

CASE DESCRIPTION

A 66-year-old male underwent a dual bifrontal and transnasal endoscopic approach for the resection of a T4N0M0 sinonasal squamous cell carcinoma. The resulting ASB defect was repaired using simultaneous pericranial and nasoseptal flaps. Adjuvant radiation therapy resulted in delayed radiation necrosis in the right frontal lobe 3 years later requiring debridement via a supraorbital approach. Recovery from this operation was complicated by an ASB defect and cerebrospinal fluid (CSF) leak. The defect remained despite multiple attempts at endoscopic repairs. Due to multiple medical comorbidities, the patient was not a candidate for microvascular reconstruction. Prior surgeries had disrupted the traditional regional flaps (i.e., pericranial, nasoseptal, and temporoparietal fascia flaps) bilaterally. Therefore the novel endoscopic-assisted paramedian forehead flap was used to successfully repair the ASB defect. Postoperatively, the patient has done well with no recurrences in the CSF leak.

CONCLUSIONS

The endoscopic-assisted paramedian forehead flap is a robust regional flap whose advantages include the utilization of muscle, low donor morbidity, and endoscopic placement with avoidance of craniotomies. Therefore it should be considered an important option for ASB reconstruction of recalcitrant CSF leaks when all other options are unavailable.

Efficacy of Cerebrospinal Fluid Fistula Repair: Sensitive Quality Control using the Beta-Trace Protein Test

Background

After cerebrospinal fluid (CSF) fistula repair, the goal of watertight sealing may not always be achieved, causing postoperative CSF leakage. The aim of this study was to assess the novel application of the beta-trace protein (betaTP) test for postoperative screening and confirmation of dura repair success.

Methods

Prospectively, we investigated 32 consecutive patients who underwent dura repair. Postoperative nasal secretion and serum were analyzed for CSF marker betaTP, to detect or rule out postoperative CSF leakage.

Results

In 29 patients no CSF was detected, indicating 91% dura repair success after the first step. Three patients required additional surgery, verifying CSF leak. Additional betaTP testing was negative, revealing successful dura repair.

Conclusion

Dura repairs should be controlled for the presence or absence of postoperative CSF leakage. In our hands, the sensitive, fast, and inexpensive betaTP test has shown its value as an effective postoperative screening tool for dura repair success confirmation. Therefore, we consider it as novel “standard of care” and reserve invasive, more expensive or time-consuming methods as second choice.

The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas

Background:

While effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and can result in a several-week period of postoperative crusting during re-mucosalization of the denuded nasal septum. Endoscopic transsphenoidal surgery for pituitary adenoma resection is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas. This flap is raised in all surgeries during the transnasal exposure using septal mucoperiosteum that would otherwise be discarded during the posterior septectomy performed in binostril approaches.

Methods:

We present a retrospective, consecutive case series of 43 patients undergoing endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure. Main outcome measures were extent of resection and postoperative CSF leak.

Results:

The mean extent of resection was 97.16 ± 1.03%. Radiographic measurement showed flap length to be adequate. While a defect in the diaphragma sellae and CSF leak were identified in 21 patients during surgery, postoperative CSF leak occurred in only one patient.

Conclusions:

The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly always successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. The flap is raised from mucoperiosteum lining the posterior nasal septum, which is otherwise resected during posterior septectomy. Because the anterior septal cartilage is not denuded, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap.

Safe intrathecal fluorescein use for identification of cerebrospinal fluid leaks: Case-report and perioperative algorithm description

Intrathecal injection of fluorescein is a method for repairing cerebrospinal fluid fistulas. The most frequent surgical procedure is endonasal endoscopy and the purpose of injecting this dye is to locate the fistula. The anaesthesiologists usually perform the puncture, therefore it is necessary to review this method and to specify some anaesthetic considerations such as correct dosing, safe management protocols and medical-legal aspects. In this case-report we describe the pre, intra and postoperative protocol of action implemented in our department that basically consists of: obtaining a specific consent, prior neurological/ophthalmologic assessment to rule out hypertension and brain damage, use of corticosteroids and previous antihistamines, choosing the correct dose and concentration of intrathecal sodium fluorescein (maximum 1ml at a concentration of 5% diluted in 9ml of cerebrospinal fluid) and close intra and postoperative monitoring.

Management of Frontal Sinus Cerebrospinal Fluid Leaks and Encephaloceles

Encephaloceles and cerebrospinal fluid (CSF) leaks of the frontal sinus may result from congenital, traumatic, spontaneous, or neoplastic causes. Paramount to success is adequate preoperative planning with accurate history, physical exam, endoscopy, imaging, and testing to confirm location of the leak and origin of the disease. Generally, frontal sinus CSF leaks may be addressed endoscopically with favorable anatomy, proper surgical technique, and appropriate equipment. Open surgical approaches (eg, osteoplastic flap) are often required for superior/lateral defects or if the surgeon is not experienced with endoscopic frontal sinus techniques.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair

BACKGROUND

Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case-series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques.

METHODS

Prospective evaluation of patients undergoing surgery for frontal sinus fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of skull base defects, complications, and clinical follow-up.

RESULTS

Forty-six patients (average age, 42 years) with frontal sinus fractures were treated using endoscopic techniques from 2008 to 2016. Mean follow-up was 26 (range, 0.5 to 79) months. Patients were treated primarily with a Draf IIb frontal sinusotomies. Draf III was used in 8 patients. Average fracture defect (length vs width) was 17.1 × 9.1 mm, and the average length involving the posterior table was 13.1 mm. Skull base defects were covered with either nasoseptal flaps or free tissue grafts. One individual required Draf IIb revision, but all sinuses were patent on final examination and all closed reductions of anterior table defects resulted in cosmetically acceptable outcomes.

CONCLUSION

Frontal sinus trauma has traditionally been treated using open approaches. Our findings show that endoscopic management should become part of the management algorithm for frontal sinus trauma, which challenges current surgical dogma regarding mandatory open approaches.

Spontaneous cerebrospinal fluid leaks in the anterior skull base secondary to idiopathic intracranial hypertension

Spontaneous cerebrospinal fluid (CSF) leaks represent a clinical entity in which CSF rhinorrhea occurs in the absence of any inciting event. Spontaneous CSF leaks are associated with elevated intracranial pressure (ICP) or have underlying idiopathic intracranial hypertension (IIH). We report a cohort of patients who have undergone nasal endoscopic repair for spontaneous CSF leaks. We review our perioperative complications and the effectiveness of the nasal endoscopic approach to repair spontaneous CSF leaks. Also, we examine the evidence correlating spontaneous CSF leaks and IIH and the role of decreasing ICP in the treatment of nasal spontaneous CSF leaks. A retrospective analysis of patients with nasal spontaneous cerebrospinal fluid leaks was performed. Data on the nature of presentation, patient body mass index, defect location and size, ICP, clinical follow-up, and complications were collected. Thirty-five patients had nasal spontaneous cerebrospinal fluid leaks with evidence of IIH's symptoms. The most common sites were the cribriform plate, the ethmoid roof, and sphenoid lateral pterygoid recess. All patients underwent endonasal endoscopic surgery to repair the defect. Postoperatively, all patients underwent lumbar drainage and acetazolamide therapy. Nasal spontaneous cerebrospinal fluid leaks represent a surgical challenge because of their high recurrence rates. The most important factor for obtaining a successful repair in these patients is reducing their intracranial pressure through nutritional, medical, or surgical means.

Otorhinolaryngological manifestations in head trauma: A prospective study of the epidemiology, clinical presentations, management, and outcomes

Background

Otorhinolaryngological injuries following head trauma may be missed, overlooked, or forgotten in the acute phase resulting in worsened management outcomes. This study aims to report the epidemiology, clinical presentations, management, and outcomes of otorhinolaryngological injuries in head trauma with a view to creating awareness for early recognition and prompt treatment.

Patients and Methods

Head injured patients consecutively presenting over a 5-year period were prospectively studied for age, gender, otorhinolaryngological presentations, interventions, and outcome of interventions. Data obtained were statistically analyzed.

Results

There were 91 (1.3%) otorhinolaryngological presentations among 7109 head injured patients. Mean age of 34 years, standard deviation = ±15.6 with a male:female ratio of 2.4:1. Severe head injury (Glasgow coma scale <9) occurred in 46 (50.5%) patients. Patients aged 30-39 years were mostly affected (n = 30; 32.9%). Most injuries were from motor vehicular accidents (n = 61; 67%) and assaults (n = 23; 25.3%). The most common otorhinolaryngological presentations were cerebrospinal fluid (CSF) rhinorrhea (n = 26; 28.6%) and CSF otorrhea (n = 25; 27.5%). Conservative management was achieved in 59.3% of patients. Mean time of hospital presentation was 13.8 h. There was no statistical correlation between outcomes and each of etiology and time of presentation (P values 0.18 and 0.9, respectively). Seventy-five (82.4%) were discharged without neurological deficits. A case fatality rate of 6.6% was recorded.

Conclusion

Frontal skull base and temporal bone fractures with CSF rhinorrhea and otorrhea are the most common injuries occurring mostly in young active males with favorable outcomes following conservative management.

Basic Imaging of Skull Base Trauma

Skull base fractures extend through the floor of the anterior, middle, or posterior cranial fossa. They are frequently associated with complex facial fractures and serious complications such as cranial nerve or vascular injury, cerebrospinal fluid leak, or meningitis. Several distinct patterns of skull base fractures have been recognized, each of them associated with different complications. Recognition of, often subtle, skull base fracture is essential to prevent or allow early treatment of these serious complications.

Tension Pneumocephalus Following Orbital Exenteration

Pneumocephalus is a known complication of skull base surgery, but is rarely seen by orbital surgeons. We report a case of postoperative mental status changes after exenteration due to tension pneumocephalus. After surgical and medical management, the patient's pneumocephalus resolved and she recovered fully. Risk factors for tension pneumocephalus, mechanism, clinical presentation, and management techniques are discussed.

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.

Patterns and sequelae of sphenoid sinus fractures

BACKGROUND

The sphenoid sinus is one of the most commonly fractured regions of the skull base after blunt head trauma. These fractures may be associated with complications such as blunt carotid artery injury (BCAI) and cerebrospinal fluid (CSF) leak. Association of these sequelae with sphenoid sinus fractures has yet to be analyzed thoroughly in the literature.

OBJECTIVE

Analyze patterns of traumatic sphenoid sinus fractures and assess relationships between fracture patterns and incidence of BCAI and traumatic nasal CSF leaks.

METHODS

A retrospective review of 123 patients sustaining sphenoid sinus fractures was performed. Patient medical records and radiographic images were reviewed. Fractures were classified based on the sinus walls involved. Logistic and linear regressions were used to analyze associations between injury mechanisms, fracture subsites, and sequelae.

RESULTS

The most commonly fractured sphenoid sinus subsites included the carotid canal, sphenoid roof, and lateral wall (60%, 49% and 48%, respectively). CSF leaks occurred in 9% of sphenoid sinus fractures, whereas BCAI occurred in 1.6%. On logistic regression, sphenoid roof fractures were significantly associated with CSF leaks (odds ratio [OR] = 12.4, p = 0.002). No fracture subsite was associated with BCAI. The positive predictive value (PPV) of sphenoid roof fractures for the presence of CSF leaks was 17%, whereas the negative predictive value (NPV) was 98%. The PPV of carotid canal fractures for BCAI was 3%, whereas the NPV was 100%. There was no association between the number of fractured sinus walls and the incidence of BCAI or CSF leak. Penetrating injuries were significantly associated with CSF leak (OR = 24.7, p = 0.01), but no other injury mechanisms were associated with BCAI or CSF leak.

CONCLUSION

Nasal CSF leak was the most common sequela of sphenoid sinus fractures, whereas BCAI was extremely uncommon. Analysis of fracture patterns can be useful in determining the need for additional evaluation.

Spontaneous cerebrospinal fluid leaks in the anterior skull base: a surgical challenge

OBJECTIVE

This retrospective study aimed to evaluate the effective closure rate for spontaneous cerebrospinal fluid leaks with functional endoscopic sinus surgery and identify patient characteristics that may be associated with a need for additional therapy.

METHOD

A retrospective analysis of patients with spontaneous cerebrospinal fluid leaks was performed. Data on the nature of presentation, patient body mass index, defect location and size, intracranial pressure, clinical follow up, and complications were collected.

RESULTS

Twenty-five patients had spontaneous cerebrospinal fluid leaks with evidence of idiopathic intracranial hypertension. The most common sites were the cribriform plate, followed by the ethmoid roof and sphenoid lateral pterygoid recess. All patients underwent endonasal endoscopic surgery to repair the defect. Post-operatively, all patients underwent lumbar drainage and acetazolamide therapy.

CONCLUSION

Spontaneous cerebrospinal fluid leaks represent a surgical challenge because of their high recurrence rates. The most important factor for obtaining a successful repair in these patients is reducing their intracranial pressure through nutritional, medical or surgical means.

Comprehensive review on endonasal endoscopic sinus surgery

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.

Treatment of cerebrospinal fluid rhinorrhea

PURPOSE OF REVIEW

Cerebrospinal fluid (CSF) rhinorrhea is a rare entity that can arise from a variety of causes. Successful management has been reported using a variety of repair techniques. The goal of this study is to make recommendations on intraoperative and postoperative management of CSF fistulas across all causes.

RECENT FINDINGS

Pooled analysis of case series reveals that free graft repairs are successful in closing most traumatic and iatrogenic CSF leaks. In contrast, multilayered, vascularized repairs are often required for large defects with high-flow leaks that communicate with a cistern and/or ventricles. Spontaneous CSF leaks are associated with idiopathic intracranial hypertension in the vast majority of cases, and when present, postoperative medical management is necessary for long-term success.

SUMMARY

Patients with CSF rhinorrhea require surgical repair to prevent life-threatening complications. Many techniques and materials are effective at achieving closure of CSF fistula across causes. Evidence suggests that patients with high-flow CSF fistulas have improved outcomes with multilayered, vascularized repairs to decrease the risk of postoperative CSF leaks. Patients with idiopathic intracranial hypertension need long-term management of the underlying disease process.

Neurologic Complications and Treatment

Risk is inherent with all surgical procedures. Most endoscopic sinus surgery (ESS) is uncomplicated. Among the many complications inherent with ESS are the neurologic complications, which include cerebrospinal fluid rhinorrhea, traumatic soft tissue and vascular injuries, infection, and seizures. Despite intense review of a patient's preoperative scans, use of stereotactic image guidance, and an expert understanding of anatomy, neurologic complications occur. An understanding of these complications and how to manage them can help to reduce long-term patient injury as well as help prevent recurrence.

Endoscopic Cerebrospinal Fluid Leak Closure in an Infected Field

Background

Sinonasal cerebrospinal fluid (CSF) leaks during an active infection present the unique challenge of preventing spread of infection without compromising the integrity of the closure. We describe the technique and clinical course of patients undergoing endoscopic CSF leak repair in an actively infected field.

Objective

To evaluate the safety and efficacy of endoscopic CSF leak repair in an actively infected field.

Methods

Retrospective chart review of patients with sinonasal CSF leaks that were endoscopically repaired during an acute infection.

Results

Nine patients were identified. Etiologies of CSF leak were iatrogenic after endoscopic sinus surgery (n = 5, 55.6%) or revision craniopharyngioma resection (n = 1, 11.1%), spontaneous (n = 1, 11.1%), anterior skull base meningocele with CSF leak (n = 1, 11.1%), and posttraumatic (n = 1, 11.1%). The locations of the leaks were ethmoid in five patients, frontoethmoid in three patients, and sphenoid in three patients. Seven patients had acute sinusitis (77.8%) and two patients had meningitis (22.2%) at the time of closure. Two patients (22.2%) had failure of previous CSF leak closure. All leaks were repaired in a multilayered fashion with multiple graft types, including septal or conchal cartilage, temporalis fascia, fascia lata, fat, Medpor, and tissue sealant. Three patients additionally had mucosal flaps or grafts. The patients were treated with an average of 11.1 days (range, 6-14 days) of antibiotics. The average hospital stay was 4.1 days (range, 2-7 days), and the mean follow-up time was 8.7 months (range, 2.9-19.3 months). No patients experienced recurrence of CSF leak or postoperative complication or infection.

Conclusion

Endoscopic closure of skull base defects was successfully performed in nine patients during acute infections without complications, recurrent infection, or need for revision CSF leak closure. Endoscopic CSF leak repair appears to be safe and effective in patients with active infection with sinusitis or meningitis.

Intracranial repair of posttraumatic cerebrospinal fluid rhinorrhea associated with recurrent meningitis

OBJECTIVE

The purposes of this study are to assess the efficacy of our intracranial surgery and evaluate the association between failure after first surgical repair and the risk factors that have been applied on a group of 13 patients affected by posttraumatic cerebrospinal fluid rhinorrhea associated with recurrent meningitis.

METHODS

We retrospectively collected data on 13 patients referred to our institution. All patients had history of head trauma and experienced 2 or more episodes of meningitis.

RESULTS

Three of the 13 patients had craniectomy defect due to previous trauma and surgery, 9 patients had linear fracture, and 1 patient had no apparent fracture line on preoperative radiologic evaluation. Ten of the 13 patients had identified frontal bone fracture involving the frontal sinus during surgery. Dural tear was identified intradurally and was repaired using a fascia lata graft with or without fibrin glue. Fibrin glue was applied over the suture in 7 patients. Three of the 13 patients had large dural defects.

CONCLUSIONS

The size of bone and dural defect seems to be an important prognostic factor of episodes of meningitis. The use of fibrin glue to fixate fascia lata graft did not benefit the outcome.

Management of anterior skull base defect depending on its size and location

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.

Risks and medico-legal aspects of endoscopic sinus surgery: a review

The aim of this study was to perform a systematic literature review of risks and medico-legal aspects of endoscopic sinus surgery. The development of sophisticated technologies and instruments for endoscopic sinus surgery (ESS) has caused a dramatic increase in the number of otolaryngologists performing sinus surgery and the number of cases performed. This expansion was accompanied by an increase in malpractice lawsuits. Over the past 20 years, rhinology claims represented 70 % of the total indemnity compensation for otolaryngology claims and ESS was the surgical procedure most often involved. Only then will a careful analysis and assessment of the possible and potential risk factors of ESS, which may mislead the surgeon, allow a correct clinical risk management, with activities and procedures aimed at reducing the possibility of complications that may expose the physician to a malpractice suit.

Tension pneumocephalus as a result of endonasal surgery: an uncommon intracranial complication

Tension pneumocephalus (TP) is a clinical entity characterized by continued build-up of air within the cranial cavity, leading to abnormal pressure exerted upon the brain and subsequent neurologic deterioration, due to development of a mass effect and potentially a herniation syndrome. Intracranial complications of endoscopic sinus surgery (ESS) and other endonasal procedures are fortunately very rare, occurring in less than 3% of cases. We report 4 cases of small bone defects (<3 mm) in the anterior cranial base accompanied by TP, caused by ESS and other endonasal procedures. The pathophysiology and management of this clinical entity is discussed with a pertinent literature. Four patients with small (<3 mm) skull base defects were identified. All patients presented with active cerebrospinal fluid leaks. CT scans showed intracranial tension pneumocephalus. Using image-guided endoscopic techniques, all defects were addressed with multi-layer repair. Closure was achieved in all patients on the first attempt, with an average follow-up of 36 months. Tension pneumocephalus is a rare event that can occur as a result of traumatic or iatrogenic violation of the dura and should be considered in all patients presenting with altered mental status after endoscopic sinus surgery or other surgical and diagnostic procedures that violate either the cranial or spinal dura. Because of the potential for rapid clinical deterioration and death, prompt brain imaging is warranted to rule out the diagnosis, and urgent neurosurgical consultation is indicated for definitive management.

Petrous bone fractures violating otic capsule

OBJECTIVE

This study presents our experience with a series of patients suffering from petrous bone fractures violating the otic capsule who underwent subtotal petrosectomy combined with eustachian tube, middle ear, and mastoid obliteration, with the goal of preventing cerebrospinal fluid (CSF) leak and meningitis.

METHODS

This study enrolled 26 patients between 1997 and 2011. The clinical symptoms, otoscopy, and preoperative and postoperative audiometry and facial function, as well as CSF leak or meningitis, were evaluated in each patient. The entire group underwent a subtotal petrosectomy using the technique described in detail by Fisch. In addition, each patient was interviewed using a questionnaire to evaluate the impact on quality of life.

RESULTS

Intraoperatively, we found significant CSF leaks in 14 patients (42.5%). No patient reported other episodes of CSF leak or meningitis after the surgery. The patients' responses of facial nerve function were slightly worse than the House-Brackmann evaluation (50% versus 42.3%; p < 0.05). The vast majority (88.5%) of the patients experienced no social impact.

CONCLUSION

Our findings suggest the importance of not underestimating the risk for CSF leak in the petrous bone fractures violating the otic capsule. Preoperative counseling regarding the various troublesome complications must adequately motivate candidates to undergo surgery by pointing out the positive impact of the proposed treatment.