Seminars in Ophthalmology, 2014; 29(5–6): 440–449 ! Informa Healthcare USA, Inc. ISSN: 0882-0538 print / 1744-5205 online DOI: 10.3109/08820538.2014.959187

REVIEW

Cerebrospinal Fluid Leak as a Complication of Oculoplastic Surgery Vicky A. Massoud1,2, Aaron Fay1,2, and Michael K. Yoon1,2 1

Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA and 2Ophthalmic Plastic and Reconstructive Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA

ABSTRACT Purpose: Cerebrospinal fluid leak is a rare, but potentially morbid complication of orbital surgery. In this review, we analyze the reported cases of CSF leak in such surgeries, determine their causes, clinical presentations and sequellae, and highlight the different methods to detect and manage them. Methods: A comprehensive literature review was conducted in PubMed. Results: Twenty-one cases of CSF leak occurred with orbital exenteration, 34 with orbital decompression, four with DCR, two with enucleation, and four cases with other skull base surgery. Operating in high-risk areas increased the risk of dural injury. Once detected, CSF leak was either controlled by bed rest and head elevation or required a surgical repair. The various techniques of surgical management are discussed. Conclusion: The number of reported surgical CSF leaks in the orbit is relatively low. To prevent this complication, it is essential to have intimate knowledge of orbital anatomy, especially in the setting of pre-existing abnormalities. If CSF leak occurs, it should be rapidly recognized and adequately managed to prevent further morbidity. Keywords: CSF, dacryocystorhinostomy, decompression, exenteration, orbit

leaks occurring during ethmoidectomy.1 Ophthalmic presentations of CSF leak are also known. In 1969, Walsh and Hoyt described a case of profuse CSF leakage through the orbit after avulsion of the eye.3 Other cases of CSF leak that presented as tearing have also been described.4–5 While some authors6 named it ‘‘pseudoepiphora,’’ Salameh et al., in 2000, suggested the term oculorrhea.7 This review summarizes the current literature on CSF leaks associated with orbital or oculoplastic surgery, describes the pathophysiology of these leaks, discusses methods to avoid them, reviews diagnostic techniques, and highlights treatment methods.

OVERVIEW In general, CSF leaks can be divided by etiology into traumatic and non-traumatic forms. Traumatic leaks can be further classified into nonsurgical (accidental) and surgical subtypes. During craniotomy, should violation of dura occur, direct closure is done when possible to prevent leaks. CSF leaks into the orbit are rare but potentially serious complications of neurosurgical, orbital, or lacrimal surgeries. Therefore, oculoplastic and orbital surgeons should be adroit in diagnosing and managing this condition. The first description of cerebrospinal fluid (CSF) leak, manifested as rhinorrhea, was by Galen in the second century, while CSF otorrhea was described in 1897 by Escat.1 These were followed by descriptions of their repair. The first intracranial approach was described by Dandy in 19262 and an extracranial approach by Doldman in 1948.2 Endoscope-assisted repair was introduced by Wigand in 1981 for repair of

MATERIALS AND METHODS Relevant medical literature was reviewed by broadly searching the PubMed database using a combination

Received 12 May 2014; revised 29 July 2014; accepted 2 August 2014; published online 24 September 2014 Correspondence: Michael K. Yoon, MD, 243 Charles Street, Boston, MA 02114, USA. E-mail: [email protected]

440

!

2014 Informa Healthcare USA, Inc.

N/A

N/A

N/A

Spontaneous closure



441

Exenteration 6

N/A – No description available IntraOp – Intraoperative IV Abx – Intravenous antibiotics B2 Tr – Beta-2 transferrin.

Exenteration 1

Limawararut et al.,14 2008 Kuo et al.,20 2011

N/A

– Gelfoam + free flap – –

N/A – Glucose N/A – CT N/A IntraOp 4 years Exenteration Exenteration Exenteration 3 1 1 Bartley et al.,22 1989 Rahman et al.,19 2005 Yuen et al.,18 2008

N/A – Clear fluid in socket –

IntraOp

– – –

– – – 1 1 1 Wulc et al.,16 1989

Exenteration Exenteration Extended exenteration

– – –

IntraOp IntraOp IntraOp

– – –

– – –

Butyl-2-Cyanoacylate + Surgicel Direct dural suture+/ Temporalis muscle fascia +/ lypophilized heteroloqous dura Dural suture + IV Abx Dural suture++ Gelatin sponge +IV Abx Dural suture + Cryanoacrylate + epicranial graft + Lumbar drain Spontaneous closure Local pericranial flap Cyanoacrylate tissue adhesive + IV abx – – – – IntraOp IntraOp (4) Day 1 (1) N/A N/A Extended exenteration 2 Exenteration 3 Extended exenteration

Lab Imaging Onset/ diagnosis Symptoms Type of surgery Cases

1 5

CSF leaks occur when there is a disruption of normal anatomical barriers. Cerebrospinal fluid is normally confined to the subarachnoid space, ventricles, and optic nerve sheath. The dura and surrounding bone further separate CSF from adjacent spaces. For a CSF leak to occur, two conditions must be present.

Reference, year

PATHOPHYSIOLOGY OF CSF LEAKS

TABLE 1. CSF leaks with orbital exenteration.

We reviewed published cases of post-surgical CSF leaks into the eye or orbit and found 24 articles describing 65 patients: 21 associated with orbital exenteration, 34 with orbital decompression, four with DCR, two with enucleation, and four cases of CSF leak with other skull base surgery. Tables 1–5 summarize the published literature. Age of patients across all reviews ranged from 18 months to 80 years (mean 46). Cerebrospinal fluid leaks into the orbit are rare, and the true incidence is difficult to determine. The majority of leaks result from accidental trauma, followed by iatrogenic leaks from surgical procedures.1 When related to orbital and ocular surgeries, they most commonly occur with skull base surgery and craniotomy. As one might expect, the prevalence of iatrogenic CSF leak in neurosurgery and otolaryngology is higher. In the former, they can occur in 1–27% of cases,8 while in the latter, surgery-related leaks constitute 20% to 30% of all encountered leaks, mainly as a complication of functional endoscopic sinus surgery (FESS).9 The incidence, presence, and outcomes of CSF leaks complicating orbital surgery may vary greatly. This is dependent on the procedure performed, the surgical approach utilized, and surgical access to the area of interest. There are limited reports or series attempting to quantify these epidemiologic values. The largest single review was by Limawararut et al., who compiled data from four institutions.10 In total, five leaks occurred from a total of 4,055 surgeries. This was subclassified by procedure as 1/154 (0.6%) with orbital exenteration, 4/397 (1%) with orbital decompression, and 0/3504 (0%) with dacryocystorhinostomy.

Treatment

EPIDEMIOLOGY OF SURGICAL CSF LEAKS

Tse et al.,21 1984 de Conciliis et al.,17 1987

Complication

of the following keywords: ‘‘cerebrospinal fluid leak,’’ ‘‘CSF leak,’’ ‘‘complication,’’ ‘‘CSF rhinorrhea,’’ ‘‘orbital decompression,’’ ‘‘dacryocystorhinostomy,’’ ‘‘DCR,’’ ‘‘exenteration,’’ ‘‘treatment,’’ ‘‘diagnosis,’’ ‘‘endoscopic surgery.’’ Articles that were taken into consideration were those of peer-reviewed Englishlanguage journals. Additionally, the relevant original articles cited in the references were also searched.

Cerebritis 1 death: Day 15: complicated course in the ICU

CSF Leak in Oculoplastics

1

2 2

1

1

Nadeau et al.,69 2005

Bailey et al.,70 2005 Paridaens et al.,25 2006

Badilla et al.,9 2007

Badilla et al.,9 2007 Fayet et al.,32 2007

Neuhaus et al.,31 1983

Reference

1 1 1 1

Cases External DCR External DCR Endoscopic DCR Endoscopic DCR

Type of surgery Rhinorrhea, Rhinorrhea, Rhinorrhea, Rhinorrhea,

headache headache headache headache

Symptoms

External medial and lateral wall

TABLE 3. CSF leaks with dacryocystorhinostomy.

2

Lynch incision: medial wall + floor

2

Graham et al.,23 2003

Limawararut et al.,14 2008

Lynch incision: medial wall + floor

2 1

Goldberg et al.,26 1997 Schaefer et al.,68 2003 Coronal: medial, lateral, floor Combined: endoscopic medial wall and external lateral wall Transcaruncular/endoscopic medial wall + external lateral wall Combined endoscopic medial wall and external lateral wall Swinging eyelid: medial + lateral + floor Swinging eyelid: medial + lateral + floor

1 15

Warren et al.,66 1989 Garrity et al.,67 1993

Transorbital (leak from fovea ethmoidalis) 2 transantral: medial wall + floor 1 transconjunctival: medial + floor Transantral medial + floor 15 transantral

Surgical approach

1 3

Cases

Tse et al., 1984 Shorr et al.,65 1986

21

Reference, year

TABLE 2. CSF leaks with orbital decompression.

Day 1 Intraop Day 1 Day 1

Onset/diagnosis

Headache, rhinorrhea, leg weakness Rhinorrhea, headache –

– –





– –

– N/A

– N/A

Symptoms

Skull X-ray Skull X-ray – CT

Imaging

IntraOp

Day 1

Day 2

IntraOp IntraOP

IntraOp

IntraOp

IntraOp IntraOp

IntraOp N/A

IntraOp N/A

Onset/ Diagnosis

Lab



B2 Tr



– –





– –

– N/A

– N/A

Lab

Treatment

Bed rest + IV Abx Bed rest + IV Abx Bed rest Endoscopic repair: cartilage + fat + Merocel

Treatment

1) Direct closure + fat graft + Tisseel + IV Abx 2) Tisseel + Abx

Bed rest

Middle nasal turbinate flap + Surgicel Leak-patching procedure 1: Temporalis muscle fascia 1: Lumbar drain for 5 days Abdominal fat graft + Tisseel

Bone wax

Spontaneous closure 9: Self-limiting 4: Surgery (N/A) Tissue glue Spontaneous closure

Butyl-2-Cyanoacylate + Surgicel Spontaneous closure

– Double-ring sign – –



CT

CT

– –





– –

– N/A

– N/A

Imaging

– – – –

Complication







– –





– –

– Meningitis (4)

Cerebritis –

Complication

442 V. A. Massoud et al.

Seminars in Ophthalmology

!





Day 3

CT

B2 Tr Aspiration of orbital fluid + lumbar drain – Percutaneous CT-guided drainage of fluid, Ventricular drain CT Day 5

– – Butyl-2-Cyanoacylate + Surgicel Lumbar drain – – – CT IntraOp Day 1

1

1 Yoon et al.,38 2014

Fronto-ethmoid mucocele – Intra + extracranial frontal and Conjunctival prolapse supraorbital rim advancement Pterional orbito-zygomatic Decreased vision, pain, craniotomy diplopia, proptosis Hemicraniotomy after pterional Proptosis orbito-zygomatic craniotomy 1 1

Symptoms Type of surgery Cases Reference

TABLE 5. Other cases of CSF leaks reported in ophthalmic literature.

Tse et al., 1984 Buckman et al.,71 1986

Complication Treatment Lab Onset/Diagnosis Imaging

CT 1 month Eyelid swelling 1 Elmalem and Harris,36 2012

2014 Informa Healthcare USA, Inc.

21

– Aspiration, Vascular clips, Dermis fat graft B2 Tr

– Transphenoidal fat graft – CT 17 yrs Headache

Enucleation (multiple glass sphere implants) Enucleation 1 Helms et al.,37 1987

Cases Reference, year

TABLE 4. CSF leaks with enucleation.

Type of surgery

Symptoms

Onset/Diagnosis

Imaging

Lab

Treatment

Complication

CSF Leak in Oculoplastics

443

The first is a defect in the arachnoid, dura, and the bone providing a physical communication between two spaces. The second requirement is a pressure gradient with higher pressure in the subarachnoid space that pushes CSF out. CSF pressure (which is proportional to intracranial pressure) varies greatly, depending on body position. When the body is in a horizontal position, the normal intracranial pressure (ICP) range is 7–15 mmHg, while it can become -10 to -15 mmHg when the body is vertical.11 When there is communication between the subarachnoid space and atmosphere (e.g. the paranasal sinuses or auditory canal), any positive ICP allows egress of CSF. However, when there is a communication into a tissue space (e.g. the orbit), the ICP must overcome the pressure of the tissues in that space for CSF to flow. With these requirements, it is not surprising that rhinologic surgeries, including septoplasty and FESS, have particularly high risk of CSF leak. When associated with FESS, the most common CSF leak sites are ethmoid/cribriform plate (80%), frontal sinus (8%), and sphenoid sinus (4%).2 Procedures in this area have a risk of violating the skull base as well as allowing intracranial communication with the sinuses. Since the sinuses are at atmospheric pressure (by definition 0 mmHg at sea level), any positive ICP will result in fluid leak causing rhinorrhea. The pathophysiology of CSF otorrhea is analogous. Neurosurgical procedures (either intracranial or spinal) very often involve entering the subarachnoid space, although leaks are relatively infrequent.12 This may be due to improved visualization with open procedures and the use of lumbar or other CSF drains postoperatively to decrease ICP.13 When leaks do occur, they most commonly occur after transsphenoidal pituitary procedures, which have endoscopic access similar to sinus/rhinologic procedures.14 Orbital exenteration has several variations based on the extent of the procedure. This surgery may remove the eye and anterior soft tissue, all the soft tissues of the orbit, may ‘‘spare’’ the eyelids to sequester the socket from external exposure,15 or may involve removal of one or several orbital walls (termed ‘‘extended’’ exenteration). The proper procedure for each patient is determined based on the clinical indication. Reports of leaks following exenteration are limited to 21 cases in eight publications.10,16–22 There are several important details to note regarding these cases. Of the 12 cases with details on the timing of leak, 10 occurred intraoperatively, one occurred on post-operative day one, and one was detected four years after surgery. ‘‘Extended’’ exenteration by definition requires more surgery and has an increased risk of dural exposure and secondary CSF leak.17 Three cases of intraoperative CSF leak were due to insertion of a needle-point monopolar

444 V. A. Massoud et al. cautery tip into a bony aperture in the orbital roof.16 Once the leak was identified intraoperatively, the bony defect was enlarged to expose the dural defect, followed by direct dural closure with suture, then packing of the orbit. This emphasizes the high risk of maneuvers adjacent to the skull base. Orbital decompression is more commonly performed than exenteration and thus has resulted in a larger number of reports. However, the incidence of CSF leak with orbital decompression is not documented in the literature. Similar to orbital exenteration, the necessary removal of bone from high-risk areas (lamina papyracea or sphenoid trigone) increases the chance of CSF leak. Balanced orbital decompression addressing the medial and lateral orbital walls is a preferred technique by some authors.23 In this technique, the greater wing of the sphenoid is removed by mechanical or piezoelectric drill,24 while the medial orbital wall is removed via an endoscopic or transcaruncular external incision. Laterally, dural tears may occur during maximal bone removal from the greater wing of sphenoid resulting in leakage.23,25,26 An important consideration is the size of the sphenoid trigone,26 which can vary from patient to patient by an order of 10.27 Furthermore, variability from one side to the contralateral side can also be substantial.27 For this reason, in addition to pre-operative evaluation of CT scans, intraoperative image guidance may be a useful adjunct during surgery.28 Some surgeons advocate using a diamond burr rather than a cutting burr to slow the rate of bone removal and decrease the risk of damage to the dura.10 In medial orbital decompression, a low-lying fovea ethmoidalis may predispose to inadvertent violation of the cribriform plate. Similar to the lateral orbit, CT scan evaluation pre- and intraoperatively may decrease the risk of this. The ethmoid vessels also demonstrate the location of the skull base.29 Some surgeons perform endoscopic medial orbital decompression, although the safety and efficacy over open approaches is unclear.30 Dacryocystorhinostomy can be associated with CSF leak due to the anatomically close relationship between the lacrimal sac fossa and the skull base. Although this is a rare complication of surgery,9,31,32 caution should be utilized when treating such patients. Typically the cribriform plate lies approximately 3 mm from the superior edge of the lacrimal fossa,33 so surgical interventions superior to this confer higher risk. Particular care should be employed in patients with known or suspected anatomic abnormalities: trauma, tumor, foreign body, etc. During external DCR, osteotomies should be performed with sharp rongeurs without any twisting or torsional movements to prevent extension of a fracture to the skull base.34,35 Fracture of an attenuated superior wall of an ethmoid air cell may erode into the

orbital roof and cause leakage as well.31 During endonasal DCR, other considerations include nasal septal deviation, the presence of which may require excessive tension against the septum, causing secondary leak.32 Therefore, some authors emphasize the need for formal septoplasty in this setting. There have been two cases of CSF leak associated with enucleation. A recent case involved development of CSF collection around the orbital implant several weeks after enucleation.36 Despite percutaneous aspiration of fluid, which confirmed the fluid as CSF, subsequent reaccumulation required ligation of the optic nerve with vascular clamps. The second report described the intracranial migration of multiple 3–4-mm-diameter glass spheres 15 years after enucleation in 1968. By eroding through the inferior orbital fissure and sphenoid sinus, the glass spheres created a fistula.37 Two cases of post-neurosurgical CSF leak into the orbit are noteworthy since they were successfully managed by lowering ICP38 (Figure 1). Yoon et al. reported one patient who developed proptosis and vision loss five days after pterional-orbitozygomatic

FIGURE 1. Top: CT scan shows left orbit after pterionalorbitozygomatic craniotomy. The arrow demonstrates the defect in the orbital roof. Note the contiguous homogenous density in the intracranial space and superolateral orbit displacing the orbital contents inferonasally. Bottom: Intraoperative photograph of right pterional-orbitozygomatic craniotomy. The arrow denotes the space between the Medpor Titan implant and the orbital contents, which is not watertight. Although there is a dural defect and potential for CSF leak, this is prevented by lowering CSF pressure via a lumbar drain. Seminars in Ophthalmology

CSF Leak in Oculoplastics craniotomy when the lumbar drain was pulled. A combination of percutaneous aspiration of orbital fluid and lowering ICP by replacement of the lumbar drain was curative. Another patient with post-operative orbital CSF causing proptosis had image-guided drainage, but had persistence of fluid. Resolution was only achieved upon lowering ICP via placement of a ventricular drain.

SYMPTOMS AND SEQUELAE OF CSF LEAKS In the reviewed literature, data regarding the timing of CSF leak detection was variably reported. In those where information was available, they were commonly identified intraoperatively (42.6%) or within the first few days after surgery (53.7%). In only two cases was there a delayed presentation: 4 and 17 years.18,37 The clinical features of CSF leak are also variable. Rhinorrhea is typically the most common presenting sign.9 CSF is clear or blood-tinged and may have a sweet taste from its glucose content (about two-thirds of blood serum glucose). The leak can be continuous or intermittent (Reservoir sign) if the fluid accumulates in the sinuses and then drains out the nose when the head is in a dependent position. This may be associated with headachem which may be relieved upon egress of the fluid from the sinus. In cases with damage to the cribriform plate, hyposomia or anosmia from concomitant damage to the olfactory nerve may be present. When drainage occurs into the orbit, there may be proptosis, eyelid swelling, or diplopia.38 Since the leak is a sign of communication between the subarachnoid space and the site of fluid, passage of pathogens through this conduit may result in intracranial infection. Symptoms include headache, stiff neck, projectile vomiting, or other meningeal signs. These are worrisome symptoms and should be evaluated emergently to prevent more serious neurologic sequelae such as seizures, occult hemorrhage, cerebral abscess, or death. Persistent leakage may present clinically as CSF hypotension syndrome characterized by postural headaches (worse when standing compared to lying down), vomiting, photophobia, decreased vision, and abducens nerve palsy.10 Due to these serious potential complications, it is imperative to make a diagnosis to manage it accordingly.

445

the origin of fluid is uncertain and laboratory analysis is required. In addition, if surgical repair of the CSF is planned, exact localization should be made.

Bedside Tests Filter paper can be used to clinically determine if fluid contains CSF. A drop of the fluid is placed in the center of the paper and the liquid is allowed to diffuse. The denser blood does not diffuse as far as the CSF, and thus, a ‘‘halo sign’’ is seen. It may also be called a ‘‘target sign’’ or ‘‘ring sign.’’ It is important to note that this sign is not pathognomonic for CSF and false positive results can occur.39 Glucose strips, which can detect the approximate concentration of glucose in a fluid, may also aid in diagnosis. The glucose level in CSF is two-thirds the serum glucose level. Comparison of the glucose levels in the suspected fluid and serum may suggest the presence of CSF. However, concomitant upper respiratory tract infection or blood in the fluid may lead to false positive results. Furthermore, there is evidence of glucose in airway secretions with stress hyperglycemia, diabetes mellitus, or nasal inflammation,40 giving this test a sensitivity and specificity of only 80%.9

Laboratory Tests Beta-2 transferrin is a desialated isoform of transferrin41 and is only found in CSF, vitreous humor, and perilymph. Therefore, its presence in suspected fluid is useful to confirm CSF. It is not altered by nasal mucous contamination and only 0.002–1 ml is required for diagnosis. First described in 1979,42 this test has a sensitivity of 97% and specificity of 99%.9 It is important to note that since beta-2 transferrin levels may be elevated in patients with liver disease, serum levels should also be measured to interpret the results.43 Beta trace protein (prostaglandin-D synthase) is another marker useful to detect CSF. It is not as specific for CSF as beta-2 transferrin since it is also present in serum and perilymph.44 Although it has been reported to have sensitivity and specificity of 100%, the presence of renal disease or bacterial meningitis make interpretation of results inconsistent.2,45

DIAGNOSIS OF CSF LEAK Localization Tests In practice, CSF leaks are generally detected by intraoperative visualization or soon after surgery (where they are a feasible complication), making the diagnosis a clinical one. However, occasionally !

2014 Informa Healthcare USA, Inc.

Once a leak is confirmed, localizing the site of the CSF leak is critical for surgical treatment. Intrathecal fluorescein injection with endoscopic transnasal CSF

446 V. A. Massoud et al. leak repair may be used. After injecting fluorescein into the subarachnoid space via lumbar puncture, a nasal endoscope is used to visualize intranasally the site of leakage. Potential complications include lower limb hypoesthesia or paresis, seizures, and cranial nerve deficits.46 One death has been attributed to the use of a large volume of highly concentrated fluorescein.47 In lieu of injection, topical application of 5% fluorescein on a pledget placed over the suspected site of the leak can also be useful. If a leak is present, the fluorescein will change color from yellow to green.9,46,48 This is likely a safe alternative to intrathecal injection for localizing the site of fistula intraoperatively49 and is the method of choice to localize leaks for some surgeons.

Neuroimaging Studies High-resolution CT scanning (HRCT) with 1.5 mm cuts and bone window is the preferred imaging modality in detecting bony defects. It can successfully identify defects in over 80% of cases.50 One limitation is the difficulty in detecting non-displaced fractures or small fissures. For this reason, combination with intrathecal radio-opaque agents such as iodinated contrast may be necessary.51 This technique shares disadvantages with previously discussed invasive techniques. Magnetic resonance imaging (MRI) and MR cisternography have better than 1 mm spatial resolution,41 making these techniques potentially useful. Reported sensitivity is 85–92% with a specificity of 100%. They can differentiate between inflammatory tissue and meningoencepahaloceles, but with reduced bony details.52 In our review of orbital CSF leaks, a variety of diagnostic techniques were used. Many of the intraoperative leak detections were made clinically upon seeing clear fluid emanating from the skull base. In 12 cases of CSF leak detected postoperatively, nine patients had a HRCT, one had a plain X-ray to detect bone fractures, three used beta-2 transferrin, and only one used the glucose oxidase test (Table 1).

MANAGEMENT OF CSF LEAKS The management of CSF leaks depends on their location, severity, and sequelae. Detection of the leak intraoperatively, versus postoperatively, also plays a role in formulating a treatment plan. Multidisciplinary planning and execution may be necessary for optimum outcomes. The aims of treatment are to stop the leak, minimize its complications, and use the lowest-risk yet most effective technique available.

Intraoperative CSF Leak A CSF leak may be seen intraoperatively as a slow, steady, or pulsatile flow of clear fluid. Rarely are tests necessary in this setting to confirm the fluid as CSF. Neurosurgical consultation intraoperatively may be prudent to evaluate for neurologic damage or assistance in closure. The main goal is decreasing flow through the defect either by creating a watertight closure or by decreasing the CSF pressure. These can be accomplished using various techniques, depending on the location and size of the dural wound. If the dura can be directly visualized and accessed, its edges may be directly opposed with suture (braided nylon or polygalactin).10 Primary closure is usually possible in cases of surgically accessible defects with intact dura. Sometimes, enlarging a small bony defect is necessary to allow improved access to the dural defect.16 However, in cases of either very large or very small leaks, or if it is difficult to identify the exact site, an onlay graft can be sutured over the leaking dura to create a watertight seal. A variety of materials have been used to close dural tears. Local vascularized flaps may be useful in the orbit. Pericranium and temporalis fascia may be successfully employed in these situations.10 These tissues may be particularly useful in patients with a history of radiation, so the flap’s blood supply allows for survival of the tissue.53 Autologous fat harvested from a variety of donor sites is the graft of choice for sphenoid and ethmoid sinus leaks.54 Other reported materials include mucosal grafts (without or with the use of bone) and free cartilage from the nasal septum or from the ear. Donor tissue, such as lyophilized heterologous dura,17 may be successfully employed, although there is a theoretical risk of disease transmission with this and all donor tissues.55 Tissue adhesives can be used to seal dura instead of suture when there is minimal loss of tissue or to secure grafts/flaps over the leak. Tisseel fibrin glue (Baxter Healthcare Corp., Deerfield, IL, USA), a human fibrinogen and bovine thrombin, can be applied over the tear to form a watertight seal.26 Cyanoacrylate (a polymer tissue glue) can be applied onto dry surgical fields to close defects.21 Neurosurgical tissue sealants may also be useful. DuraSeal (Confluent Surgical, Inc., Waltham, MA, USA), is a combination of two components that form a hydrogel which can decrease CSF flow through the tear and allow for spontaneous healing.56 BioGlue (Cryolife, Inc, Kenneshaw, GA, USA), although comprised of different components, also forms a sealant with long-lasting effects.57 In cases where there is pinpoint leakage of CSF through bone, application of bone wax may tamponade flow into the orbit. This, in turn, can give time for the dura to heal spontaneously.23 However, excessive use of wax in the orbit should be avoided, as it may Seminars in Ophthalmology

CSF Leak in Oculoplastics prevent fibrin deposition and may cause an inflammatory reaction.58,59

Post-Operative CSF Leak If the CSF leak is detected post-operatively, alternative repair methods may be employed. In cases where the leak is slow, conservative measures can be utilized. The head should be kept elevated to 30+ degrees, as this will reduce intracranial pressure (and thus CSF pressure). The patient should avoid Valsalva maneuvers: strenuous activity, coughing or nose blowing, and straining. Stool softeners, antiemetics, and antitussives can prevent Valsalva-related spikes in ICP.2 Bed rest may be advised. Furthermore, placement of a lumbar drain can maintain a low ICP, which can permit healing of the defect and sealing of the leak.38 Surgeons maintain the drain for a variable duration, but five to six days is common. These conservative measures may result in resolution of the leak in 85– 100% of patients.60,61 Surgical intervention may be necessary if the leak persists after conservative treatment, if secondary sequelae develop, or optic neuropathy develops.38 If a compartment syndrome or similar complication of CSF collection occurs, then immediate action should be taken. This may be by either open or percutaneous drainage with or without image guidance (CT or ultrasound). Imaging studies may help to pinpoint the location of these leaks. Traditionally, external approaches (e.g. Lynch incision) for leaks into the sinus were most common, although less invasive endoscopic techniques are becoming more prevalent with similar success rates.22,62 Once again, it is important to note that combined closure of the leak and lowering the ICP may maximize the chance of success. The role of antibiotics with CSF leaks is unclear. Although commonly used, prophylactic antibiotics likely do not decrease the rate of meningitis in traumatic CSF leaks.63,64 Their role in post-operative leaks is uncertain.

CONCLUSION Cerebrospinal fluid leaks are rare but serious complications of oculoplastic surgery. The sequela of such fistulas may be serious, including meningitis, cerebritis, seizure, and death. Prevention is key with intimate knowledge of the anatomy and thorough pre-operative clinical and radiological assessment of the patient. Should a leak occur, proper diagnostic techniques must be used so that treatment may be initiated. Management may range from conservative measures to open surgical closure with tissue grafts or flaps. !

2014 Informa Healthcare USA, Inc.

447

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES 1. Sumitha R, Hari PM, Rayma Kumar S, Hariprasad R. A case of cerebrospinal fluid rhinorrhea. J Clin Diagn Res 2013;7(7):1447–9. 2. Prosser J, Vender J, Solares C. Traumatic cerebrospinal fluid leaks. Otolaryngol Clin N Am 2011;44:857–873. 3. Walsh FB, Hoyt WF. Clinical Neuroophthalmology, 3rd ed. Baltimore: Williams & Wilkins, 1969;551–566. 4. Joshi KK, Crockard HA. Traumatic cerebrospinal fluid fistula simulating tears: case report. J Neurosurg 1978;49: 121–123. 5. Till JS, Marion JR. Cerebrospinal fluid masquerading as tears. South Med J 1980;80:639–640. 6. Galzio RJ, Lucantoni D, Zinobii M, et al. Traumatic craniopalpebral cerebrospinal fluid fistula. J Neurosurg Sci 1981;25:105–107. 7. Salame K, Segev Y, Fliss D M, Ouaknine GE. Diagnosis and management of posttraumatic oculorrhea. Neurosurg Focus 2000;9(1):1–4. 8. Bernardo L, Bernardo WM, Bor Seng Shu E, et al. Does the use of Duraseal in head and spinal surgeries reduce the risk of cerebrospinal fluid leaks and complications when compared to conventional methods of dura mater closure? Rev Assoc Med Bras 2012;58(4):402–403. 9. Badilla J, Dolman P. Cerebrospinal fluid leaks complicating orbital or oculoplastic surgery. Arch Ophthalmol 2007;125: 1631–1634. 10. Limawararut V, Valenzuela A, Sullivan T, et al. Cerebrospinal fluid leaks in orbital and lacrimal surgery. Surv Ophthalmol 2008;53:274–284. 11. Chapman PH, Cosman ER, Arnold MA. The relationship between ventricular fluid pressure and body position in normal subjects and subjects with shunts: a telemetric study. Neurosurgery 1990;26(2):181–189. 12. Ebersold M. Five things oculoplastic surgeons should know about neurosurgery. Ophthal Plast Reconstr Surg 2000; 16:247–249. 13. Constantini S, Cotev S, Rappaport H, et al. Intracranial pressure monitoring after elective intracranial surgery. J Neurosurg 1988;69:540–544. 14. Hobbs CGL, Darr A, Carlin WV. Management of intraoperative cerebrospinal fluid leak following endoscopic trans-sphenoidal pituitary surgery. J Laryngol Otol 2011;125: 311–313. 15. Shields JA, Shields CL, Suvarnamani C, et al. Orbital exenteration with eyelid sparing: indications, technique, and results. Ophthalmic Surg 1991;22:292–297. 16. Wulc AE, Adams JL, Dryden RM. Cerebrospinal fluid leakage complicating orbital exenteration. Arch Ophthalmol 1989;107:827–830. 17. de Conciliis C, Bonavolonta G. Incidence and treatment of dural exposure and CSF leak during orbital exenteration. Ophthal Plast Reconstr Surg 1987;3:61–194. 18. Yuen H, Cheng A, Auyeung KC. Late-onset occult cerebrospinal fluid leakage after orbital exenteration. Ophthal Plast Reconstr Surg. 2008;24:238–239. 19. Rahman I, Cook AE, Leatherbarrow B. Orbital exenteration: a 13-year Manchester experience. Br J Ophthalmol 2005;89:1335–1340.

448 V. A. Massoud et al. 20. Kuo CH, Gao K, Clifford A, et al. Orbital exenterations: an 18-year experience from a single head and neck unit. ANZ J Surg 2011;81(5):326–30. 2010. 21. Tse DT, Panje WR, Anderson RL. Cyanoacrylate adhesive used to stop CSF leaks during orbital surgery. Arch Ophthalmol 1984;102:1337–1339. 22. Bartley G, Garrity J, Waller R, et al. Orbital exenteration at the Mayo clinic. Ophthalmology 1989;96:468–474. 23. Graham SM, Brown CL, Carter KD, et al. Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease. Laryngoscope 2003;113:1206–1209. 24. De Castro DK, Fay A, Wladis EJ, et al. Self-irrigating piezoelectric device in orbital surgery. Ophthal Plast Reconstr Surg 2013;29(2):118–122. 25. Paridaens D, Lie A, Grootendorst RJ, et al. Efficacy and side effects of ‘‘swinging eyelid’’ orbital decompression in Graves’ orbitopathy: a proposal for standardized evaluation of diplopia. Eye 2006;20:154–162. 26. Goldberg RA, Weinberg DA, Shorr N, et al. Maximal, three-wall, orbital decompression through a coronal approach. Ophthal Surg Lasers 1997;28:832–843. 27. Lefebvre DR, Yoon MK. CT-based measurements of the sphenoid trigone in different gender and race. ASOPRS 2013, New Orleans, LA. 28. Selva D, Chen C, Wormald PJ. Frontoethmoidal osteoma: a stereotactic-assisted sino-orbital approach. Ophthal Plast Reconstr Surg 2003;19:237–238. 29. Leone CR, Piest KL, Newman RJ. Medial and lateral wall decompression for thyroid ophthalmopathy. Am J Ophthalmol 1989;108:160–166. 30. Boboridis KG, Bunce C. Surgical orbital decompression for thyroid eye disease. Cochrane Database Syst Rev 2011;12: CD007630. 31. Neuhaus RW, Baylis HI. Cerebrospinal fluid leakage after dacryocystorhinostomy. Ophthalmology 1983;90:1091–1095. 32. Fayet B, Racy E, Assouline M. Cerebrospinal fluid leakage after endonasal dacryocystorhinostomy. J Fr Ophthalmol 2007;30:129–134. 33. Kurihashi K, Yamashita A. Anatomical consideration for dacryocystorhinostomy. Ophthalmology 1991;203:1–7. 34. Bagheri A, Naghibozakerin J, Yazdani S. Cerebrospinal fluid leakage during dacryocystorhinostomy in a patient with meningoencephalocele. Eur J Ophthalmol 2005;15: 500–503. 35. Botek A, Goldberg S. Margins of safety in dacryocystorhinostomy. Ophthal Surg 1993;24:320–322. 36. Elmalem VI, Harris GJ. Occurrence and surgical management of a cerebrospinal fluid-filled cystoid space following rountine enucleation. Ophthal Plast Reconstr Surg 2012; 28(5):e117–e119. 37. Helms H, Zeiger H, Callahan A. Complications following enucleation and implantation of multiple glass spheres in the orbit. Ophthal Plast Reconstr Surg 1987;3: 87–89. 38. Yoon MK, Piluek WJ, Ruggiero J, et al. Orbital cerebrospinal fluid accumulation after complicated pterionalorbitozygomatic craniotomy. J Neurophthalmol 2014. Epub ahead of print. Avilable from: http://www.ncbi.nlm.nih. gov/pubmed/24699141 [last accessed 16 Sep 2014]. 39. Nirmal Kumar K, Thiagarajan B. Cerebrospinal fluid rhinorrhoes: an overview. Otorhinolaryngology 2012; 3(5):WMC003382. 40. Philipps BJ, Meguer JX, Redman J, et al. Factor determining the appearance of glucose in upper and lower respiratory tract secretions. Intens Care Med 2003;29:2204–2210. 41. Mantur M, Lukaszewicz-Zajac B, Mroczko B, et al. Cerebrospinal fluid leakage: reliable diagnostic methods. Clin Chim Act 2011;412:837–840.

42. Meurmann OH, Irjala K, Suonpa˜a˜ J, et al. A new method for the identification of cerebrospinal fluid leakage. Acta Otolaryngol 1979;87:366–369. 43. Bell H, Tallaksen C, Sjaheim T, et al. Serum carbohydratedeficient transferrin as a marker of alcohol consumption in patients with chronic liver diseases. Alcohol Clin Exp Res 1993;17:246–252. 44. Warnecke A, Averbeck T, Wurster U, et al. Diagnostic relevance of b2-transferrin for the detection of cerebrospinal fluid fistulas. Arch Otolaryngol Head and Neck Surg 2004;130:1178–1184. 45. Schnabel C, Di Martino E, Gilsbach J, et al. Comparison of b2-transferrin and b-trace protein for detection of cerebrospinal fluid in nasal and ear fluids. Clin Chem 2004;50:661–663. 46. Saafan M, Ragab S, Albirmawy O. Topical intranasal fluorescein: the missing partner in algorithms of cerebrospinal fluid detection. Laryngoscope 2006;116:1158–1161. 47. Senior BA, Jafri K, Benninger M. Safety and efficacy of endoscopic repair of CSF leaks and encephaloceles: a survey of the members of the American Rhinologic Society. Am J Rhinol 2001;15:21–25. 48. Jones ME, Reino T, Gnoy A, et al. Identification of intranasal cerebrospinal fluid leaks by topical application with fluorescein dye. Am J Rhinol 2000;14:93–96. 49. Liy H, Chen Y, Wang D, et al. The use of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid rhinorrhea. Surg Neurol 2009;72:341–346. 50. Botek AA, Goldberg SH. Margins of safety in dacryocystorhinostomy. Ophthal Surg 1993;24:320–322. 51. Meco C, Oberascher G, Arrer E, et al. Beta-trace protein test: new guidelines for the reliable diagnosis of cerebrospinal fluid fistula. Otolaryngol Head Neck Surg 2003;129: 508–517. 52. Sillers MJ, Morgan E, El Cammal T. magnetic resonance cisternography and thin coronal computerized tomography in the evaluation of cerebrospinal fluid rhinorrhea. Am J Rhinol 1997;11:387–392. 53. Pinheiro-Neto CD, Snyderman CH. Nasoseptal flap. Adv Otorhinolaryngol 2013;74:42–55. 54. Ziu M, Jimenez DF. The history of autologous fat graft use for prevention of cerebrospinal fluid rhinorrhea after transsphenoidal approaches. World Neurosurg 2013;80: 554–562. 55. Martinez-Lage JF, Perez-Espejo MA, Palazon JH, et al. Autologous tissues for dural grafting in children: a report of 56 cases. Childs Nervous Syst 2005;22:139–144. 56. Boogarts JD, Grotenhuis JA, Bartels RH, et al. Use of a novel absorbable hydrogel for augmentation of dural repair: results of a preliminary clinical study. Neurosurg 2005;57:146–151. 57. Kumar A, Maartens NF, Kaye AH. Evaluation of the use of BioGlue in neurosurgical procedures. J Clin Neurosci 2003; 10:661–664. 58. Bolger WE, Tadros M, Ellenbogen RG, et al. Endoscopic management of cerebrospinal leak associated with the use of bone wax in skull-base surgery. Otolaryngol Head Neck Surg 2005;132:418–420. 59. Katz SE, Rootman J. Adverse effects of bone wax in surgery of the orbit. Ophthal Plast Reconstr Surg 1996;12:121–126. 60. Brawley BW, Kelly WA. Treatment of basal skull fractures with and without cerebrospinal fluid fistulae. J Neurosurg 1967;26:57–61. 61. Platt MP, Parnes SM. Management of unexpected cerebrospinal fluid leak during endoscopic sinus surgery. Curr Opin Otolargol Head Neck Surg 2009;17:28–32. 62. Locatelli D, Rampa F, Acchiardi I, et al. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience. Neurosurgery 2006;58:246–275. Seminars in Ophthalmology

CSF Leak in Oculoplastics 63. Yilmazlar S, Arslan E, Kocaeli H, et al. Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases. Neurosurg Rev 2006;29:64–71. 64. Ratial BO, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2006;1:CD004884. 65. Shorr N, Seiff SR. The four stages of surgical rehabilitation of the patient with dysthyroid ophthalmopathy. Ophthalmology 1986;93:476–483. 66. Warren J, Spector J, Burde R. Long-term follow-up and recent observations on 305 cases of orbital decompression for dysthyroid orbitopathy. Laryngoscope 1989;99:35–40. 67. Garrity J, Fatourechi V, Bergstralh E, et al. Results of transantral orbital decompression in 428 patients with

!

2014 Informa Healthcare USA, Inc.

68.

69.

70.

71.

449

severe Graves’ ophthalmopathy. Am J Ophthalmol 1993;116: 533–547. Schaefer SD, Soliemanzadeh P, Della Rocca DA, et al. Endoscopic and transconjunctival orbital decompression for thyroid-related orbital apex compression. Laryngoscope 2003;113:508–513. Nadeau S, Pouliot D, Molgat Y. Orbital decompression in Graves’ orbitopathy: a combined endoscopic and external lateral approach. J Otolaryngol 2005;34:109–115. Bailey KL, Tower RN, Dailey RA. Customized, singleincision, three-wall orbital decompression. Ophthal Plast Reconstr Surg 2005;21:1–9. Buckman G, Levine M. Treatment of prolapsed conjunctiva. Ophthal Plast Reconstr Surg 1986;2:33–39.

Copyright of Seminars in Ophthalmology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Cerebrospinal fluid leak as a complication of oculoplastic surgery.

Cerebrospinal fluid leak is a rare, but potentially morbid complication of orbital surgery. In this review, we analyze the reported cases of CSF leak ...
454KB Sizes 0 Downloads 12 Views