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Original Article
Endoscopic management of CSF rhinorrhea Rajesh Reddy Sannareddy, K. Rambabu1, Vinay EC Kumar1, Ratnam Boola Gnana, Alok Ranjan Departments of Neurosurgery, and 1Otorhinolaryngology, Apollo Health City, Hyderabad, Andhra Pradesh, India
Abstract
Address for correspondence: Dr. Rajesh Reddy Sannareddy, Department of Neurosurgery, Apollo Institute of Neurosciences, Apollo Health City, Jubilee Hills, Hyderabad ‑ 500 096, Andhra Pradesh, India. E‑mail: [email protected] Received : 28‑07‑2014 Review completed : 07‑08‑2014 Accepted : 03‑10‑2014
Background: Transnasal endoscopic repair has become the treatment of choice for most anterior cranial and all sphenoid sinus breaches. The aim of this paper is to evaluate the results of endoscopic management of cerebrospinal fluid (CSF) rhinorrhea in a tertiary care center in South India. Materials and Methods: A retrospective analysis of 40 consecutive patients who underwent endoscopic repair of CSF rhinorrhea between 2010 and 2013 was performed. Endoscopic procedure consisted of defining the defect and removal of mucosa for 3-4 mm surrounding it. Repair was done using septal cartilage (for defects involving sphenoid sinus where sinus was packed with fat), fascia lata, oxidized cellulose, and fibrin sealant. Lumbar drain was placed for 2-4 days in selected cases. A lumbar‑peritoneal shunt was inserted in patients with spontaneous CSF rhinorrhea and high opening lumbar CSF pressure. Results: Spontaneous CSF leaks were more common in middle‑aged females, whereas posttraumatic CSF leaks were common in young adult males. The success rates following first surgery for patients with posttraumatic, spontaneous, and postprocedural CSF leaks were 85.7, 81.8, and 75%, respectively, which improved to 95.7, 100, and 100% following second procedure, respectively. Technical failures, poor graft uptake because of radiation therapy, location of leak in the lateral sphenoid recess, lumbar peritoneal shunt malfunction, and poor healing of skull base fractures were responsible for recurrence of leak. Conclusion: Team work between neurosurgeons and otorhinolaryngologists with attention to identification of site of leak, preparation of graft bed, securing the graft in place, and postoperative care is critical to achieve a high level of success for endoscopic repair of CSF rhinorrhea. Key words: Cerebrospinal fluid rhinorrhea, endoscopy, surgical repair
Introduction Cerebrospinal fluid (CSF) rhinorrhea is a result of breakdown of physiological barriers that separate the subarachnoid space and the nasal cavity. Surgical repair is required to prevent life‑threatening complications, such as meningitis and brain abscess, that can otherwise Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144453
532
be seen in 10-40% of patients during follow‑up. [1] Endoscopic repair has become increasingly popular ever since Wigand reported the first endoscopic repair of CSF leak in 1981. [2] The excellent illumination, stereoscopic view of anatomical details of the skull base, lack of morbidity associated with craniotomy and documented success rates of >90% in expert hands have made transnasal endoscopic repair the procedure of choice for most anterior cranial fossa and sphenoid sinus CSF leaks.[3] Unlike the intracranial approach, the endoscopic approach provides better illumination and higher success rates with minimal morbidity.[3‑6] The objective of this study was to analyze the results of endoscopic management of CSF rhinorrhea by a team of neurosurgeons in collaboration with otorhinolaryngologists. Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
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used (Karl Storz, Tuttlingen, Germany). Ethmoid sinus leaks were accessed with an ethmoidectomy, cribriform region with a partial middle turbinectomy, and sphenoid sinus through a paraseptal approach via the sphenoid ostium [Figure 1]. After identifying the defect, the graft bed was prepared by removing a cuff of normal mucosa and fibrous tissue off the bone for 3-4 mm surrounding the defect. Bipolar cautery was applied to facilitate repair when arachnoid and dura mater herniated through a bony defect. The repair was performed by a neurosurgeon using fat (harvested from thigh), fascia lata, oxidized cellulose, and fibrin sealant. A piece of nasal septal cartilage was used to cover bony defects of size >1 cm. The nasal pack was placed in the nasal cavity at the end of procedure.
Materials and Methods A retrospective analysis of 40 consecutive patients who underwent endoscopic management for CSF rhinorrhea between 2010 and 2013 was performed. Details pertaining to the etiology of CSF leak, clinical presentation, surgical procedure, and hospital stay were collected. All the patients were followed up in the outpatient department or interviewed over telephone after discharge. Confirmation of CSF rhinorrhea was made by estimating the glucose levels in the watery discharge. Further evaluation included high‑resolution computed tomography (CT) scan of paranasal sinuses or magnetic resonance (MR) cisternogram, as was deemed appropriate. In patients with contraindication for MRI, a CT cisternogram was performed. Opening lumbar CSF pressure was measured in patients with spontaneous CSF rhinorrhea. Patients with traumatic CSF rhinorrhea presenting after 48 h underwent CSF analysis to rule out meningitis. All patients with meningitis were treated with intravenous antibiotics for atleast 5 days before surgery.
The indications for lumbar drain placement were presence of active CSF leak or multiple areas of CSF leak noted intraoperatively, dural defect, encephalocele and bone defect in the skull base > 1 cm. Lumboperitoneal shunt was inserted in patients with spontaneous CSF rhinorrhea having high opening CSF pressure on lumbar puncture. For patients undergoing endoscopic repair for traumatic CSF rhinorrhea, a concomitant repair of frontal sinus was performed by frontal sinusotomy through a supraorbital mini‑eyebrow incision when the inner table of frontal sinus was fractured and displaced [Figure 2]. In patients undergoing surgical
The initial part of the surgery was performed by an otorhinolaryngologist. Under general anesthesia, nasal mucosa was decongested with infiltration of 1:10,000 adrenaline solution. Rigid Hopkins rod‑lens telescopes of 0 and 30° with a 4‑mm diameter were
a
b
c
d
Figure 1: Illustration of technique of endoscopic repair of CSF leak in patients with cribriform defect (a), ethmoid defect (b). The technique for visualization of sphenoid recess in patients with sphenoid encephaloceles has been illustrated (c). Intraoperative photograph (d) Fascia lata graft being laid over the skull base defect, which has been covered with fat and fibrin sealant after defining the margins of the defect and removal of mucosa around it. CSF = Cerebrospinal fluid
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b
a
c
e
d
f
Figure 2: Illustration of supraorbital frontal sinusotomy. (a) Skin incision along the medial third of the eyebrow. (b) Elevation of outer table of frontal sinus with a chisel and hammer. (c) Note that the bone flap is not completely detached all around and is still attached to the pericranium on one end. (d) Frontal sinus mucosa is removed; site of CSF leak is identified and repaired with fascia lata, fat and fibrin sealant. (e) Bone flap is replaced and secured to the edges. (f) Pericranium, if replaced over the bone and surgical wound, is closed in layers
repair for traumatic CSF rhinorrhea, all sites of skull base fractures noted on preoperative CT scan were carefully inspected intraoperatively for evidence of dural breach or CSF leak. During the postoperative period, measures were taken to prevent elevation of intracranial pressure, and patients were advised not to blow their nose. Lumbar CSF drainage was performed at 3-5 ml/h until nasal packs were removed on postoperative day 3. The lumbar drain was clamped for the next 24 h and removed if there was no evidence of CSF leak. The first follow‑up visit was scheduled between 2 and 4 weeks after discharge, and subsequent visits were planned per the convenience of the patient. Telephonic interviews were carried out for patients who were not compliant with follow‑up.
Results A total of 40 patients underwent the surgical repair during the study period: Traumatic (n = 21), spontaneous (n = 11), and postprocedural or iatrogenic (n = 8). Male gender predilection was noted in the posttraumatic and postprocedural leaks. Spontaneous leaks were more common in female patients (age group 40-59 years) [Table 1]. The incidence of traumatic CSF leaks was highest in young adult males (20-39 years). Most patients presented with a watery discharge from the nostril. Clinical presentation consistent with meningitis was noted in five posttraumatic leaks, two postprocedural leaks, and one spontaneous leak. Postprocedural leaks were observed in five patients following transsphenoidal resection of pituitary adenoma, two patients following 534
resection of clinoidal meningioma, and one patient with orbital adenoid cystic carcinoma. The most common site of leak in patients with postprocedural CSF leak was sphenoid sinus (seven of eight patients), whereas cribriform and sphenoid were the most common sites of leak in five and four patients with spontaneous CSF leak (n = 11), respectively. In posttraumatic CSF leaks, multiple sites of leaks were frequently observed. A supraorbital frontal sinusotomy through a mini‑eyebrow incision was performed in 8 of the 21 posttraumatic leaks for management of associated frontal sinus defect. A concomitant lumbar thecoperitoneal shunt was placed in two patients with spontaneous CSF leak, as the opening CSF pressure was found to be high during routine preoperative evaluation. One patient each in the posttraumatic and postprocedural CSF leak groups underwent lumbar peritoneal shunt placement during the second surgery. One patient who had recurrence of leak following repair for spontaneous CSF leak had a defect in the lateral sphenoid recess with an associated encephalocele, which was difficult to delineate. Another patient in the same group had lumbar peritoneal shunt malfunction, which caused a CSF leak from a site different from that of the previous surgery. Both patients in the postprocedural group who had CSF leak manifested following radiation therapy for the primary tumor. Of the three failures in the posttraumatic group, two patients had recurrence of leak from the same site, whereas the third one developed a leak from another large defect in the floor of the anterior cranial fossa. All, but one, recurrent leaks were successfully repaired with a second endoscopic approach. Of the seven failures, CSF leak was noted in four of them Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
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Table 1: Summary of patients in our series (n = 40)
CSF - Cerebrospinal fluid
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during the primary admission. The other patients became symptomatic 5, 17, and 23 months following the first surgical repair. No morbidity or mortality related to the surgical procedure was noted in our series.
large defect (>15 mm), recurrent leaks, and leaks associated with a meningocele.[16] Our indication for lumbar drain placement in 80% of our patients was justified on the basis of the criteria suggested by Hegazy et al.
Discussion
In a meta‑analysis of 55 studies involving 1,778 fistula repairs, Psaltis et al., observed a success rate of 90.6% following first endoscopic repair for CSF rhinorrhea, which improved to 96.6% following a second endoscopic procedure.[7] The success rate in the largest series of endoscopic repair of CSF leaks reported by Kirtane et al., was 96.63% following first surgery and 98.88% after revision surgery [Table 2].[8] Castelnuovo et al., reviewed the literature for 286 endoscopic CSF leak repairs and found 28 cases of failure at the first attempt. Most authors, however, failed to specify the precise site of failure and did not offer any further details. From their experience of failures, it emerged that meticulous technique with accurate preparation of the margins and graft coverage of at least 5 mm from the margins was important.[25] Factors that might predispose to failure of the treatment are the inability to identify the defect, inadequate preparation of the defect area before positioning the graft, spontaneous CSF leak, elevated body mass index, location of leak in lateral sphenoid, and a massive skull base defect.[26‑28]
In this series, the incidence of posttraumatic CSF leaks was higher than spontaneous and postprocedural leaks, which was in contrast to the results of meta‑analysis where the prevalence of spontaneous leaks was high.[7,16] Posttraumatic leaks were more common in males aged 20-39 years, whereas spontaneous leaks were more common in females aged 40-59 years. Sphenoid and cribriform plate were the commonest sites for spontaneous CSF leaks, whereas posttraumatic patients had CSF leaks from multiple sites, with cribriform plate and sphenoid being common sites in majority of them.[7‑15] Hence, it is important to inspect all sites corresponding to skull base fractures for evidence of dural breach or CSF leak in patients presenting with traumatic CSF rhinorrhea. The key to endoscopic transnasal surgical repair of the leak is accurate preoperative location of the site of leak, meticulous preparation of the recipient bed, and accurate placement of the graft material.[3,6] In their meta‑analysis, Hegazy et al., found no statistically significant difference among different grafting techniques and materials.[16] In our series, repair of the skull base defect was performed with fat, fascia lata, oxidized cellulose, and fibrin sealant. A piece of nasal septal cartilage was used to cover sphenoid ostia after packing the sinus with fat and fibrin glue. The efficacy of fibrin glue in preventing CSF leaks remains controversial. Although histopathological studies suggest that fibrin glue may trigger an inflammatory response that may promote healing, studies have reported a success rate of 97% with fibrin glue and 92–100% without glue.[11,12,16‑19] Mohindra et al., evaluated CSF leaks in 27 pediatric patients and found no statistically significant difference in outcome of endoscopic repairs with or without fibrin glue.[20] Rodney et al., suggested that if tissue adhesives are used, they must be applied conservatively because a thick layer of adhesive may prevent the graft material from coming in contact with the wound bed.[21] Several authors have reported successful results with relatively consistent use of lumbar drain, whereas others have reported similar results without lumbar drain placement.[22‑24] On the basis of a meta‑analysis of 14 studies comprising 289 CSF fistulae repairs, Hegazy et al., advocated the use of lumbar drains for 3-5 days with idiopathic leaks, posttraumatic leaks, leaks associated with 536
Spontaneous CSF leaks have the highest recurrence rate following surgical repair (25–87%), compared with 15 mm) or a meningoencephalocele. Patients with CSF leak caused by sphenoid encephaloceles are at increased risk of recurrence and should be counseled appropriately while obtaining informed consent.
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intracranial pressures in spontaneous cerebrospinal fluid leaks. Am J Rhinol 2003;17:191‑5. Casiano RR, Jassir D. Endoscopic cerebrospinal fluid rhinorrhea repair: Is a lumbar drain necessary? Otolaryngol Head Neck Surg 1999;121:745‑50. Anand VK, Murali RK, Glasgold MJ. Surgical decisions in the management of cerebrospinal fluid rhinorrhoea. Rhinology 1995;33:212‑8. Roland PS, Marple BF, Meyerhoff WL, Mickey B. Complications of lumbar spinal fluid drainage. Otolaryngol Head Neck Surg 1992;107:564‑9. Castelnuovo P, Mauri S, Locatelli D, Emanuelli E, Delù G, Giulio GD. Endoscopic repair of cerebrospinal fluid rhinorrhoea: Learning from our failures. Am J Rhinol 2001;15:333‑42. Zweig JL, Carrau RL, Celin SE, Schaitkin BM, Pollice PA, Synderman CH, et al. Endoscopic repair of cerebrospinal fluid leaks to the rhinonasal tract: Predictors of success. Otolaryngol Head Neck Surg 2000;123:195‑201. Basu D, Haughey BH, Hartman JM. Determinants of success in endoscopic cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg 2006;135:769‑73. Lindstrom DR, Toohill RJ, Loehrl TA, Smith TL. Management of cerebrospinal fluid rhinorrhoea: The medical college of Wisconsin experience. Laryngoscope 2004;114:969‑74. Bolger WE, Osenbach R. Endoscopic transpterygoid approach to the lateral sphenoid recess. Ear Nose Throat J 1999;78:36‑46. Alexander NS, Chaaban MR, Riley KO, Woodworth BA. Treatment strategies for lateral sphenoid sinus recess cerebrospinal fluid leaks. Arch Otolaryngol Head Neck Surg 2012;138:471‑8. Hubbard JL, McDonald TJ, Pearson BW, Laws ER Jr. Spontaneous cerebrospinal fluid rhinorrhea: Evolving concepts in diagnosis and surgical management based on the Mayo Clinic experience from 1970 through 1981. Neurosurgery 1985;16:314‑21. Har‑El G. What is spontaneous cerebrospinal fluid rhinorrhea? Classification of cerebrospinal fluid leaks. Ann Otol Rhinol Laryngol 1999;108:323‑6. Wang EW, Vandergrift WA, Schlosser RJ. Spontaneous CSF leaks. Otolaryngol Clin North Am 2011;44:845‑56. Seth R, Rajasekaran K 3rd, Luong A, Benninger MS, Batra PS. Spontaneous CSF leaks: Factors predictive of additional interventions. Laryngoscope 2010;120:2141‑6.
35. Woodworth BA, Prince A. Chiu AG. Spontaneous CSF leaks: A paradigm for definitive repair and management of intracranial hypertension. Otolaryngol Head Neck Surg 2008;138:715‑20. 36. Chaaban MR, Illing E, Railey KO, Woodworth BA. Spontaneous cerebrospinal fluid leak repair: A five year prospective evaluation. Laryngoscope 2014;124:70‑5. 37. Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH. Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 2007;117:1133‑7. 38. Patel MR, Taylor RJ, Hackman TG, Germanwala AV, Sasaki‑Adams D, Ewend MG, et al. Beyond the nasoseptal flap: Outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction. Laryngoscope 2014;124:846‑52. 39. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: Vascular pedicle nasoseptal flap. Laryngoscope 2006;116:1882‑6. 40. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, et al. Endoscopic reconstruction of the cranial base using pediclednasoseptal flap. Neurosurgery 2008;63:ONS44‑52. 41. Fortes FS, Carrau RL, Snyderman CH, Prevedello D, Vescan A, Mintz A, et al. The posterior pedicle inferior turbinate flap: A new vascularised flap for skull base reconstruction. Laryngoscope 2007;117:1329‑32. 42. Fortes FS, Carrau RL, Snyderman CH, Kassam A, Prevedello D, Vescan A, et al. Transpterygoid transposition of a temporoparietal fascial flap: A new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 2007;117:970‑6. 43. Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high‑flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus 2012;32:E7. 44. Zuckerman J, Stankiewicz JA, Chow JM. Long‑term outcomes of endoscopic repair of cerebrospinal fluid leaks and meningoencephaloceles. Am J Rhinol 2005;19:582‑7. How to cite this article: Sannareddy RR, Rambabu K, Kumar VE, Gnana RB, Ranjan A. Endoscopic management of CSF rhinorrhea. Neurol India 2014;62:532-9. Source of Support: Nil, Conflict of Interest: None declared.
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Original Article
Endoscopic management of CSF rhinorrhea Rajesh Reddy Sannareddy, K. Rambabu1, Vinay EC Kumar1, Ratnam Boola Gnana, Alok Ranjan Departments of Neurosurgery, and 1Otorhinolaryngology, Apollo Health City, Hyderabad, Andhra Pradesh, India
Abstract
Address for correspondence: Dr. Rajesh Reddy Sannareddy, Department of Neurosurgery, Apollo Institute of Neurosciences, Apollo Health City, Jubilee Hills, Hyderabad ‑ 500 096, Andhra Pradesh, India. E‑mail: [email protected] Received : 28‑07‑2014 Review completed : 07‑08‑2014 Accepted : 03‑10‑2014
Background: Transnasal endoscopic repair has become the treatment of choice for most anterior cranial and all sphenoid sinus breaches. The aim of this paper is to evaluate the results of endoscopic management of cerebrospinal fluid (CSF) rhinorrhea in a tertiary care center in South India. Materials and Methods: A retrospective analysis of 40 consecutive patients who underwent endoscopic repair of CSF rhinorrhea between 2010 and 2013 was performed. Endoscopic procedure consisted of defining the defect and removal of mucosa for 3-4 mm surrounding it. Repair was done using septal cartilage (for defects involving sphenoid sinus where sinus was packed with fat), fascia lata, oxidized cellulose, and fibrin sealant. Lumbar drain was placed for 2-4 days in selected cases. A lumbar‑peritoneal shunt was inserted in patients with spontaneous CSF rhinorrhea and high opening lumbar CSF pressure. Results: Spontaneous CSF leaks were more common in middle‑aged females, whereas posttraumatic CSF leaks were common in young adult males. The success rates following first surgery for patients with posttraumatic, spontaneous, and postprocedural CSF leaks were 85.7, 81.8, and 75%, respectively, which improved to 95.7, 100, and 100% following second procedure, respectively. Technical failures, poor graft uptake because of radiation therapy, location of leak in the lateral sphenoid recess, lumbar peritoneal shunt malfunction, and poor healing of skull base fractures were responsible for recurrence of leak. Conclusion: Team work between neurosurgeons and otorhinolaryngologists with attention to identification of site of leak, preparation of graft bed, securing the graft in place, and postoperative care is critical to achieve a high level of success for endoscopic repair of CSF rhinorrhea. Key words: Cerebrospinal fluid rhinorrhea, endoscopy, surgical repair
Introduction Cerebrospinal fluid (CSF) rhinorrhea is a result of breakdown of physiological barriers that separate the subarachnoid space and the nasal cavity. Surgical repair is required to prevent life‑threatening complications, such as meningitis and brain abscess, that can otherwise Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144453
532
be seen in 10-40% of patients during follow‑up. [1] Endoscopic repair has become increasingly popular ever since Wigand reported the first endoscopic repair of CSF leak in 1981. [2] The excellent illumination, stereoscopic view of anatomical details of the skull base, lack of morbidity associated with craniotomy and documented success rates of >90% in expert hands have made transnasal endoscopic repair the procedure of choice for most anterior cranial fossa and sphenoid sinus CSF leaks.[3] Unlike the intracranial approach, the endoscopic approach provides better illumination and higher success rates with minimal morbidity.[3‑6] The objective of this study was to analyze the results of endoscopic management of CSF rhinorrhea by a team of neurosurgeons in collaboration with otorhinolaryngologists. Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
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used (Karl Storz, Tuttlingen, Germany). Ethmoid sinus leaks were accessed with an ethmoidectomy, cribriform region with a partial middle turbinectomy, and sphenoid sinus through a paraseptal approach via the sphenoid ostium [Figure 1]. After identifying the defect, the graft bed was prepared by removing a cuff of normal mucosa and fibrous tissue off the bone for 3-4 mm surrounding the defect. Bipolar cautery was applied to facilitate repair when arachnoid and dura mater herniated through a bony defect. The repair was performed by a neurosurgeon using fat (harvested from thigh), fascia lata, oxidized cellulose, and fibrin sealant. A piece of nasal septal cartilage was used to cover bony defects of size >1 cm. The nasal pack was placed in the nasal cavity at the end of procedure.
Materials and Methods A retrospective analysis of 40 consecutive patients who underwent endoscopic management for CSF rhinorrhea between 2010 and 2013 was performed. Details pertaining to the etiology of CSF leak, clinical presentation, surgical procedure, and hospital stay were collected. All the patients were followed up in the outpatient department or interviewed over telephone after discharge. Confirmation of CSF rhinorrhea was made by estimating the glucose levels in the watery discharge. Further evaluation included high‑resolution computed tomography (CT) scan of paranasal sinuses or magnetic resonance (MR) cisternogram, as was deemed appropriate. In patients with contraindication for MRI, a CT cisternogram was performed. Opening lumbar CSF pressure was measured in patients with spontaneous CSF rhinorrhea. Patients with traumatic CSF rhinorrhea presenting after 48 h underwent CSF analysis to rule out meningitis. All patients with meningitis were treated with intravenous antibiotics for atleast 5 days before surgery.
The indications for lumbar drain placement were presence of active CSF leak or multiple areas of CSF leak noted intraoperatively, dural defect, encephalocele and bone defect in the skull base > 1 cm. Lumboperitoneal shunt was inserted in patients with spontaneous CSF rhinorrhea having high opening CSF pressure on lumbar puncture. For patients undergoing endoscopic repair for traumatic CSF rhinorrhea, a concomitant repair of frontal sinus was performed by frontal sinusotomy through a supraorbital mini‑eyebrow incision when the inner table of frontal sinus was fractured and displaced [Figure 2]. In patients undergoing surgical
The initial part of the surgery was performed by an otorhinolaryngologist. Under general anesthesia, nasal mucosa was decongested with infiltration of 1:10,000 adrenaline solution. Rigid Hopkins rod‑lens telescopes of 0 and 30° with a 4‑mm diameter were
a
b
c
d
Figure 1: Illustration of technique of endoscopic repair of CSF leak in patients with cribriform defect (a), ethmoid defect (b). The technique for visualization of sphenoid recess in patients with sphenoid encephaloceles has been illustrated (c). Intraoperative photograph (d) Fascia lata graft being laid over the skull base defect, which has been covered with fat and fibrin sealant after defining the margins of the defect and removal of mucosa around it. CSF = Cerebrospinal fluid
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b
a
c
e
d
f
Figure 2: Illustration of supraorbital frontal sinusotomy. (a) Skin incision along the medial third of the eyebrow. (b) Elevation of outer table of frontal sinus with a chisel and hammer. (c) Note that the bone flap is not completely detached all around and is still attached to the pericranium on one end. (d) Frontal sinus mucosa is removed; site of CSF leak is identified and repaired with fascia lata, fat and fibrin sealant. (e) Bone flap is replaced and secured to the edges. (f) Pericranium, if replaced over the bone and surgical wound, is closed in layers
repair for traumatic CSF rhinorrhea, all sites of skull base fractures noted on preoperative CT scan were carefully inspected intraoperatively for evidence of dural breach or CSF leak. During the postoperative period, measures were taken to prevent elevation of intracranial pressure, and patients were advised not to blow their nose. Lumbar CSF drainage was performed at 3-5 ml/h until nasal packs were removed on postoperative day 3. The lumbar drain was clamped for the next 24 h and removed if there was no evidence of CSF leak. The first follow‑up visit was scheduled between 2 and 4 weeks after discharge, and subsequent visits were planned per the convenience of the patient. Telephonic interviews were carried out for patients who were not compliant with follow‑up.
Results A total of 40 patients underwent the surgical repair during the study period: Traumatic (n = 21), spontaneous (n = 11), and postprocedural or iatrogenic (n = 8). Male gender predilection was noted in the posttraumatic and postprocedural leaks. Spontaneous leaks were more common in female patients (age group 40-59 years) [Table 1]. The incidence of traumatic CSF leaks was highest in young adult males (20-39 years). Most patients presented with a watery discharge from the nostril. Clinical presentation consistent with meningitis was noted in five posttraumatic leaks, two postprocedural leaks, and one spontaneous leak. Postprocedural leaks were observed in five patients following transsphenoidal resection of pituitary adenoma, two patients following 534
resection of clinoidal meningioma, and one patient with orbital adenoid cystic carcinoma. The most common site of leak in patients with postprocedural CSF leak was sphenoid sinus (seven of eight patients), whereas cribriform and sphenoid were the most common sites of leak in five and four patients with spontaneous CSF leak (n = 11), respectively. In posttraumatic CSF leaks, multiple sites of leaks were frequently observed. A supraorbital frontal sinusotomy through a mini‑eyebrow incision was performed in 8 of the 21 posttraumatic leaks for management of associated frontal sinus defect. A concomitant lumbar thecoperitoneal shunt was placed in two patients with spontaneous CSF leak, as the opening CSF pressure was found to be high during routine preoperative evaluation. One patient each in the posttraumatic and postprocedural CSF leak groups underwent lumbar peritoneal shunt placement during the second surgery. One patient who had recurrence of leak following repair for spontaneous CSF leak had a defect in the lateral sphenoid recess with an associated encephalocele, which was difficult to delineate. Another patient in the same group had lumbar peritoneal shunt malfunction, which caused a CSF leak from a site different from that of the previous surgery. Both patients in the postprocedural group who had CSF leak manifested following radiation therapy for the primary tumor. Of the three failures in the posttraumatic group, two patients had recurrence of leak from the same site, whereas the third one developed a leak from another large defect in the floor of the anterior cranial fossa. All, but one, recurrent leaks were successfully repaired with a second endoscopic approach. Of the seven failures, CSF leak was noted in four of them Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
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Table 1: Summary of patients in our series (n = 40)
CSF - Cerebrospinal fluid
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during the primary admission. The other patients became symptomatic 5, 17, and 23 months following the first surgical repair. No morbidity or mortality related to the surgical procedure was noted in our series.
large defect (>15 mm), recurrent leaks, and leaks associated with a meningocele.[16] Our indication for lumbar drain placement in 80% of our patients was justified on the basis of the criteria suggested by Hegazy et al.
Discussion
In a meta‑analysis of 55 studies involving 1,778 fistula repairs, Psaltis et al., observed a success rate of 90.6% following first endoscopic repair for CSF rhinorrhea, which improved to 96.6% following a second endoscopic procedure.[7] The success rate in the largest series of endoscopic repair of CSF leaks reported by Kirtane et al., was 96.63% following first surgery and 98.88% after revision surgery [Table 2].[8] Castelnuovo et al., reviewed the literature for 286 endoscopic CSF leak repairs and found 28 cases of failure at the first attempt. Most authors, however, failed to specify the precise site of failure and did not offer any further details. From their experience of failures, it emerged that meticulous technique with accurate preparation of the margins and graft coverage of at least 5 mm from the margins was important.[25] Factors that might predispose to failure of the treatment are the inability to identify the defect, inadequate preparation of the defect area before positioning the graft, spontaneous CSF leak, elevated body mass index, location of leak in lateral sphenoid, and a massive skull base defect.[26‑28]
In this series, the incidence of posttraumatic CSF leaks was higher than spontaneous and postprocedural leaks, which was in contrast to the results of meta‑analysis where the prevalence of spontaneous leaks was high.[7,16] Posttraumatic leaks were more common in males aged 20-39 years, whereas spontaneous leaks were more common in females aged 40-59 years. Sphenoid and cribriform plate were the commonest sites for spontaneous CSF leaks, whereas posttraumatic patients had CSF leaks from multiple sites, with cribriform plate and sphenoid being common sites in majority of them.[7‑15] Hence, it is important to inspect all sites corresponding to skull base fractures for evidence of dural breach or CSF leak in patients presenting with traumatic CSF rhinorrhea. The key to endoscopic transnasal surgical repair of the leak is accurate preoperative location of the site of leak, meticulous preparation of the recipient bed, and accurate placement of the graft material.[3,6] In their meta‑analysis, Hegazy et al., found no statistically significant difference among different grafting techniques and materials.[16] In our series, repair of the skull base defect was performed with fat, fascia lata, oxidized cellulose, and fibrin sealant. A piece of nasal septal cartilage was used to cover sphenoid ostia after packing the sinus with fat and fibrin glue. The efficacy of fibrin glue in preventing CSF leaks remains controversial. Although histopathological studies suggest that fibrin glue may trigger an inflammatory response that may promote healing, studies have reported a success rate of 97% with fibrin glue and 92–100% without glue.[11,12,16‑19] Mohindra et al., evaluated CSF leaks in 27 pediatric patients and found no statistically significant difference in outcome of endoscopic repairs with or without fibrin glue.[20] Rodney et al., suggested that if tissue adhesives are used, they must be applied conservatively because a thick layer of adhesive may prevent the graft material from coming in contact with the wound bed.[21] Several authors have reported successful results with relatively consistent use of lumbar drain, whereas others have reported similar results without lumbar drain placement.[22‑24] On the basis of a meta‑analysis of 14 studies comprising 289 CSF fistulae repairs, Hegazy et al., advocated the use of lumbar drains for 3-5 days with idiopathic leaks, posttraumatic leaks, leaks associated with 536
Spontaneous CSF leaks have the highest recurrence rate following surgical repair (25–87%), compared with 15 mm) or a meningoencephalocele. Patients with CSF leak caused by sphenoid encephaloceles are at increased risk of recurrence and should be counseled appropriately while obtaining informed consent.
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