Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks

OBJECTIVE: To analyze possible etiological factors of spontaneous cerebrospinal fluid (CSF) rhinorrhea and to assess the outcomes of endonasal endoscopic repair. DESIGN: Retrospective study. SETTING: Academic neurosurgical hospital.Patients Twenty-one consecutive patients who presented with spontaneous CSF leak and underwent endonasal endoscopic surgery from January 1999 through December 2001. INTERVENTION: Preoperative examination included computed tomographic scans; nasal endoscopy; measurement of glucose concentration in the nasal discharge; and, in some cases, cisternographic evaluations via computed tomography and/or magnetic resonance imaging. Telescopes, conventional endoscopic sinus surgery instruments, and a microdebrider were used for all patients who underwent endonasal surgery. A combination of plastic materials, ie, abdominal fat, fascia lata, rotated middle turbinate flaps, and fibrin glue, were used for fistula repair. RESULTS: At the time of surgery, CSF fistulas were found in the cribriform plate (6 patients), in the fovea ethmoidalis (6 patients), and in the sphenoid sinus (9 patients). In 5 of the 6 patients who had an extremely pneumatized sphenoid sinus, the source of the leak was located in the lateral extension of the sinus. A meningocele protruding through the bone defect was the source of the leak in 10 patients. Postoperative follow-up lasted from 9 to 42 months, and 20 patients were considered cured. There was only 1 recurrence, in a patient whose CSF rhinorrhea originated in the deep lateral recess of an overpneumatized sphenoid sinus. Thus, the overall success rate was 95.2%. There were no postoperative complications. CONCLUSIONS: Possible etiological factors of this disease include obesity, congenital malformations of the skull base, an overpneumatized sphenoid sinus (particularly in its lateral extensions), and the empty sella syndrome. Endoscopic endonasal repair of spontaneous CSF rhinorrhea appears to be a safe and successful procedure. However, techniques for endoscopic closure of CSF fistulas in the lateral part of the sphenoid sinus need further perfecting.     

Endonasal endoscopic repair of Sternberg's canal cerebrospinal fluid leaks

OBJECTIVES: Management of cerebrospinal fluid leaks or encephaloceles of Sternberg's canal is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of the study was to assess the real effectiveness of an endoscopic endonasal approach for treating cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus. STUDY DESIGN: The authors conducted a retrospective evaluation. METHODS: Clinical charts of patients with cerebrospinal fluid leaks and/or encephaloceles of Sternberg's canal treated at our institution were retrospectively reviewed. All these patients were managed with an endonasal endoscopic procedure. RESULTS: Fifteen patients (9 female and 6 male) were included in this study. Nine patients underwent a transethmoidal-pterygoidal-sphenoidal approach with a multilayer reconstructive technique. No cerebrospinal fluid leak recurrences were observed during follow up (mean follow up 37.6 +/- 21.7 standard deviation months) CONCLUSIONS: The transethmoidal-pterygoidal-sphenoidal approach provides a wide, safe, and direct route to the lateral recess of the sphenoid sinus. Multilayered reconstruction of the skull base defects must be considered the first option for this kind of lesion.     

Endoscopic management of sphenoid sinus cerebrospinal fluid leaks

OBJECTIVES: Cerebrospinal fluid (CSF) leaks that originate within the sphenoid sinus pose a unique surgical challenge due to difficulties with access and visualization The objective of this report is to illustrate concepts for the successful management of sphenoid sinus CSF leaks. METHODS: Retrospective data analysis was performed on 9 patients who presented to a tertiary care medical center for endoscopic repair of a sphenoid sinus CSF leak from January 2002 to January 2006. RESULTS: The patient cohort included 7 women and 2 men with a mean age of 51.7 years. In 5 cases the CSF leak was caused by a previous neurosurgical procedure; the other 4 cases were idiopathic. An endoscopic pterygomaxillary fossa approach was required in 4 cases. A layered reconstruction of the sphenoid sinus wall with collagen allografts (cadaveric acellular dermal allograft, 8 patients; bovine collagen membrane, 1 patient) and mucosa under endoscopic visualization with intraoperative surgical navigation was performed in all cases. The reconstruction was buttressed with autologous bone in 2 cases and with cartilage in 2 cases. Fibrin sealant was used in 7 cases. Two patients developed transient diabetes insipidus after the repair. Two patients developed a recurrent CSF leak necessitating revision repair 2 and 15 months, respectively, after the initial repair procedure. The average hospital stay was 6.5 days. The mean length of follow-up was 21.1 months. CONCLUSIONS: This series demonstrates that minimally invasive endoscopic repair of sphenoid sinus CSF leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Extended endoscopic approaches, including the pterygomaxillary fossa approach, may be useful in selected instances.     

Long-term outcomes of endoscopic repair of cerebrospinal fluid leaks and meningoencephaloceles

BACKGROUND: The management and surgical approach to cerebrospinal fluid (CSF) leaks and meningoencephaloceles have undergone transformation throughout the last 10 years. It is our interest to examine the long-term surgical outcome and reoccurrence rates of CSF leaks or meningoencephaloceles in patients having endoscopic surgical repair. METHODS: We performed a retrospective evaluation of 50 patients that underwent endoscopic surgical repair of a CSF leak, meningoencephalocele, or both, between September 1985 and October 2003. RESULTS: Cumulatively, reoccurrence rates were 15% (7/47) among the CSF leak patients with an average time frame for reoccurrence ranging from 1 to 25 months (average, 7 months). Patients with meningoencephaloceles had an overall reoccurrence rate of 8% (1/13). In addition, a Medline search on CSF leaks and meningoencephaloceles provided the names of 32 authors that have studied outcomes of endoscopic surgical repair. Of the 151 patients still followed in the 5- to 10-year postoperative group, there were 37 recurrences of CSF leaks and 5 reoccurrences of the meningoencephaloceles with a total recurrence rate of 27% (37 + 5/151). Of the 19 patients still followed in the >10-year postoperative group, there were three reoccurrences of CSF leaks and no reoccurrences of meningoencephaloceles, giving a reoccurrence rate of 16% (3 + 0/19). CONCLUSION: Based on our cumulative results, a reoccurrence of a CSF leak or meningoencephalocele after endoscopic repair will occur within the first 2 years postoperatively. Once patients pass these postoperative time frames they are relatively free of reoccurrence from this very effective surgical management. Endoscopic repair results are better than craniotomy with much less morbidity.     

Transnasal endoscopic closure of cerebrospinal fluid leaks

OBJECTIVES/HYPOTHESIS: To demonstrate an effective method for transnasal endoscopic closure of anterior skull base fistulas that does not involve lumbar drains or fat packing. STUDY DESIGN: Retrospective. METHODS: We reviewed the charts of 36 patients who had 37 anterior skull base defects that were repaired endoscopically between 1993 and 2001. RESULTS: Thirty-three defects were successfully closed on the first attempt. Three were successfully closed on the second attempt. One large defect was repaired by neurosurgery after a failed endoscopic attempt. Our results are similar to those of other published series. CONCLUSION: Our method is effective and does not require adjuvant procedures or prolonged hospital stays.     

内镜经鼻浴缸塞技术在儿童脑脊液鼻漏修补术中的应用

目的探讨内镜经鼻浴缸塞技术在儿童脑脊液鼻漏修补术中的安全性和有效性。方法回顾性分析2016年9月—2019年9月北京儿童医院耳鼻咽喉头颈外科收治的16例脑脊液鼻漏患儿的临床资料。其中男10例,女6例,年龄5~123月龄,中位年龄57.5月龄。患儿常规进行鼻窦薄层CT及MRI检查,并进行了全身麻醉下经鼻内镜浴缸塞技术脑脊液鼻漏修补术。术后定期随访,对手术效果及并发症进行评估。对所有患儿的人口学特点、症状、体征、颅底漏口位置及面积、治疗及预后情况等进行归纳总结。结果16例患儿中,外伤性脑脊液鼻漏7例,先天性脑脊液鼻漏9例。单纯性脑脊液鼻漏2例,合并基底型脑膜脑膨出14例。颅底漏口分别为左侧筛板6例,右侧筛板4例,左侧筛顶2例,右侧筛顶1例,左侧额窦后壁2例,右侧蝶窦顶壁1例。漏口最大直径1~4 mm 4例,5~10 mm 7例,11~20 mm 5例。其中15例手术获得一次性成功,仅1例额窦后壁外伤性脑脊液漏内镜手术修补失败,改由神经外科行开颅修补术。术后随访24~60个月,中位随访时间32.5个月,均未复发或出现并发症。结论内镜经鼻浴缸塞技术法儿童脑脊液鼻漏修补术是一种安全、有效的手术方式,具有操作简便、创伤小、并发症少等优点。     

Transcochlear repair of persistent cerebrospinal fluid leaks.

OBJECTIVE: The purpose of this study is to demonstrate the utility of a modified transcochlear obliteration of the petrous apex in repair of persistent cerebrospinal fluid (CSF) leaks. A review of temporal bone computed tomography (CT) scans and histological preparations for potential air cells leading to such leaks is also presented. STUDY DESIGN: Retrospective case review in an academic tertiary referral center. METHODS: Patients for inclusion in this study had previously undergone either a suboccipital or translabyrinthine removal of an intracranial tumor with subsequent transmastoid and middle ear obliteration of air cell tracts to stop a CSF leak. Ninety CT scans and 178 temporal bones were reviewed and assessed for peritubal and petrous apex pneumatization. RESULTS: Four patients had initial obliteration of the orifice of the eustachian tube and middle ear that failed to prevent leakage of CSF. The leak was ultimately controlled by a transcochlear petrous apicectomy. From The Ohio State University temporal bone collection, 178 specimens were available for examination. Peritubal pneumatization was found in 42% of the bones examined. The CT scans showed unilateral petrous apex pneumatization in 30% of the specimens and bilateral pneumatization in 11%. CONCLUSIONS: Continuity of air cell tracts from the petrous apex surrounding the internal auditory canal to the medial eustachian tube can provide a path for CSF rhinorrhea that is difficult to stop by conventional means. A modified transcochlear approach successfully terminated persistent leaks in four such patients.     

经额经鼻内镜联合径路修补额窦脑脊液鼻漏

目的 建立一种治疗额窦脑脊液鼻漏的新技术。方法 7例额窦脑脊液鼻漏，5例行经额一鼻内镜联合径路额窦脑脊液鼻漏修补术，其余2例行单纯经鼻内镜脑脊液鼻漏修补术。结果 4例一次手术修补成功：2例接受了二次手术，另1例三次手术才修补成功。平均随访3年。尽管7例脑脊液鼻漏最终都修补成功，但接受经额经鼻内镜联合径路手术的病人比单纯行经鼻内镜脑脊液鼻漏修补术的病人术后恢复快得多。结论 经额一鼻内镜联合径路是额窦脑脊液鼻漏治疗的首选手术径路。     

Endoscopic repair of cerebrospinal fluid leaks after neurosurgical procedures

OBJECTIVES: Endoscopic repair of cerebrospinal fluid (CSF) leaks has proven to be effective and safe. CSF rhinorrhea is a well-known complication of neurosurgical procedures in the anterior cranial fossa. We present a series of endoscopic repairs of CSF rhinorrhea secondary to neurosurgical procedures. STUDY DESIGN: Retrospective review of 13 cases. METHODS: Thirteen patients are included in the study. Eleven had CSF leaks after hypophysectomy, one after clipping of an anterior circle of Willis aneurysm, and one after posttraumatic frontal lobe debridement. Leaks were identified intraoperatively during the neurosurgical procedure (n = 8) or with intrathecal fluorescein injection during a separate procedure (n = 5). Repair was performed by exposing the skull base defect, debriding the defect margins, and sealing the defect with a free mucosal graft or abdominal fat. RESULTS: Leaks were identified in the sphenoid (n = 12) and posterior ethmoid (n = 1) sinuses. Nine patients had lumbar drains placed. One patient had recurrence of CSF rhinorrhea 2 months after initial repair requiring a revision procedure. No other recurrences were noted. One patient developed postoperative meningitis requiring intravenous antibiotics and a prolonged hospital stay. No other postoperative complications were observed. CONCLUSIONS: Endoscopic repair is a safe and effective treatment for CSF rhinorrhea encountered as a neurosurgical complication.     

Nasal endoscopic repair of cerebrospinal fluid rhinorrhea

The surgical management of Cerebro-spinal Fluid (CSF) rhinorrhea has been modified these last years due to the improvement of endoscopic sinus surgery techniques allowing the treatment of selective dural tears by the endonasal route. Over a period of 6 years, 27 patients with CSF rhinorrhea were operated on by the endonasal approach under optical guidance. CSF rhinorrhea was due, in 20 cases, to surgical iatrogenic trauma, in 4 cases to head injury, and in 1 case it was secondary to a conservative medical treatment of a pituitary adenoma. In 2 cases the cause was unknown. The average follow-up in this series was 24.7 months. The technique used was successful in 22 patients (81.5%). Considering these results and others reported in the literature, we think the use of the endonasal approach with optical guidance should always be considered as a valuable alternative to open surgery and should be discussed in all cases of CSF rhinorrhea with neurosurgeons.     

鼻内镜下脑脊液鼻漏修补术

目的 探讨鼻内镜下脑脊液鼻漏修补术的手术方法和治疗效果.方法 回顾性分析1996-2010年诊断为脑脊液鼻漏的54例患者的临床资料,所有患者均行鼻内镜下脑脊液鼻漏修补术.其中,外伤性25例,自发性17例,医源性12例.采用颞肌、颞肌筋膜、中鼻甲黏膜、鼻中隔黏膜、下鼻甲黏膜、阔筋膜、大腿肌肉、腹部脂肪、钩突黏膜、鼻窦黏膜等进行修复.结果 54例患者中,49例一次修补成功,1例2次手术修补成功,1例3次手术修补成功,1例在外院再次手术成功,1例修补不成功,未再治疗,1例术后1年半复发,未再治疗.术后并发症:4例术后出现高热,1例术后出现一过性浅昏迷并高热,1例术后出现癫痫,1例患者术后出现气颅,均经保守治疗痊愈.结论 鼻内镜下脑脊液鼻漏修补术是一种安全、有效和微创的手术方式,手术成功率高,应作为首选治疗方法;准确的漏口定位,选择合适的入路和适宜的修补方法是手术成功的关键.     

鼻内镜下脑脊液鼻漏修补术

我们于2000—05—2011-10经鼻内镜修补脑脊液鼻漏31例,取得较满意的效果,报告如下。     

Traumatic cerebrospinal fluid leaks

This article discusses the epidemiology, diagnosis, and management of traumatic cerebrospinal fluid (CSF) leaks. An overview of traumatic CSF leaks is presented, and both conservative and operative therapies are reviewed. Management decisions are discussed based on the current literature. Controversial clinical topics are addressed, including the use of prophylactic antibiotics and the timing of surgical repair.     

Nasal cerebrospinal fluid leaks

Otolaryngologists are increasingly being called on to assist with the evaluation and management of skull base defects that result in cerebrospinal fluid (CSF) leaks and meningoencephaloceles. A thorough understanding of the underlying pathophysiology and a critical analysis of management principles and treatment options are essential to achieve the best possible results for these patients. This review article highlights the physiology, pathophysiology, diagnosis, surgical technique, and postoperative care relevant to CSF leak and encephalocele patient care for otolaryngologists with a special emphasis on the differences between CSF leaks of varying etiologies.     

Lateral sphenoid sinus recess cerebrospinal fluid leak: a case series

The lateral recess of the sphenoid sinus is one of the most common sites of meningocele and spontaneous cerebrospinal fluid (CSF) leak. Despite the availability of several techniques for closure of skull base defects occurring in this location, recurrence still poses a major challenge. This report reviews the experience of surgical repair of lateral sphenoid sinus recess CSF leak at a tertiary referral center and provides a brief discussion of this rare lesion. Nine surgeries were performed for six cases of spontaneous lateral sphenoid sinus recess CSF leak (two revisions and one repair of a new defect). Two patients presented with intracranial hypertension (ICH) and four with meningocele or meningoencephalocele. The transpterygoid approach was used in two procedures. A multilayer graft was used in seven cases and a nasoseptal flap in two. Three patients received lumbar or ventricular shunts, and one received acetazolamide for ICH management. Two minor complications were recorded, and the overall surgical success rate was 78 %. We conclude that nasoseptal flaps are a valid option for repair of recurrent CSF leaks, particularly in the lateral sphenoid sinus recess. Furthermore, identification and correction of ICH plays an essential role in the success of treatment in this patient population.