脑脊液鼻漏修补术成败的关键因素研究

目的：总结脑脊液鼻漏的治疗经验。方法：回顾性分析16例脑脊液鼻漏患者的临床资料,探讨脑脊液鼻漏的病因、影像学特点及漏口位置、大小、修复方法对疗效的影响。结果：16例患者中自发性脑脊液鼻漏10例,外伤性脑脊液鼻漏2例,感冒后出现脑脊液鼻漏3例,脑膜脑膨出伴脑脊液鼻漏1例。CT检查明确漏口位置11例,磁共振水成像检查明确漏口位置7例。漏口位于额窦3例,鼻腔顶部3例,筛顶6例,蝶窦4例。手术均在鼻内镜下完成,修补材料均采用自体材料;均一次修复成功,无手术并发症发生。随访10-42个月,无一例复发。结论：术前应用CT和磁共振水成像能准确判断脑脊液鼻漏漏口的位置、大小,术中修补材料的选择、漏口周围移植床的处理及修补材料与移植床的完全接触是确保手术成功的重要因素。     

Endonasal endoscopic repair of anterior skull-base fistulas: the Kuala Lumpur experience

The purpose of this retrospective study is to determine the pattern of cerebrospinal fluid (CSF) rhinorrhoea presenting to our tertiary referral centre in Kuala Lumpur and to assess the clinical outcomes of endonasal endoscopic surgery for repair of anterior skull base fistulas. Sixteen patients were treated between 1998 and 2004. The aetiology of the condition was spontaneous in seven and acquired in nine patients. In the acquired category, three patients had accidental trauma and this was iatrogenic in six patients (five post pituitary surgery), with one post endoscopic sinus surgery (ESS). Imaging included computed tomography (CT) scan and magnetic resonance imaging (MRI). Endoscopic repair is less suited for defects in the frontal sinuses with prominent lateral extension and defects greater than 1.5 cm in diameter involving the skull base. Fascia lata, middle turbinate mucosa, nasal perichondrium and ear fat ('bath plug') were the preferred repair materials in the anterior skull base, whereas fascia lata, cartilage and abdominal fat obliteration was preferentially used in the sphenoid leak repair. Intrathecal sodium flourescein helped to confirm the site of CSF fistula in 81.3 per cent of the patients. Ninety per cent of the patients who underwent 'bath plug' repair were successful. The overall success rate for a primary endoscopic procedure was 87.5 per cent, although in two cases a second endoscopic procedure was required for closure. In the majority of cases endoscopic repair was successful, and this avoids many of the complications associated with craniotomy, particularly in a young population. Therefore it is our preferred option, but an alternative procedure should be utilized should this prove necessary.     

Topical intranasal fluorescein: the missing partner in algorithms of cerebrospinal fluid fistula detection

OBJECTIVE: The aim of this work was to focus on the development and validation of the use of topical fluorescein in the intraoperative localization of cerebrospinal fluid (CSF) fistulas, and to screen its use in preoperative diagnosis of CSF rhinorrhea as well as postoperative detection of a recurrence. MATERIALS AND METHODS: Twenty-five patients with CSF rhinorrhea were treated with an endoscopic endonasal technique. Topical intranasal 5% fluorescein was used for preoperative diagnosis and intraoperative localization of the site of the leak. A change in the color of the fluorescein from yellow to green fluorescence and sometimes streaming the fluorescein over the nasal mucosa and blood denoted the presence of CSF, and the site of the leak could be traced. RESULTS: The cause of the leak was accidental trauma in 11 patients, spontaneous in 9 patients, and iatrogenic in 5 patients. The ethmoidal roof was the most common site of leak (52%) followed by the cribriform plate (40%) and then the sphenoid sinus (8%). We have achieved 100% success rate in sealing the CSF fistulas in our 25 patients with no recurrence detected during the follow-up period (mean, 19+/-10 months). The preoperative use of fluorescein-soaked cotton pledgets was 100% accurate in diagnosing CSF rhinorrhea when compared with B2 transferrin testing. The intraoperative use of topical intranasal fluorescein was also 100% accurate in locating the site of the CSF fistula when compared with the surgical findings. No major complications have been reported. CONCLUSION: In the presence of a clinically diagnosed CSF leakage, topical fluorescein is a very easy, sensitive, safe, and highly accurate tool in the intraoperative localization of the site and extent of CSF fistulas, and should be considered a viable noninvasive alternative to intrathecal fluorescein. We also recommend its use as a simple and quick outpatient clinic test for preoperative diagnosis of CSF rhinorrhea. It can be used postoperatively as well when there is a doubt of recurrence of the CSF leak.     

Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience

INTRODUCTION: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses. METHODS: A retrospective review of CSF leak management was conducted. This study included patients with CSF rhinorrhea managed by the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, from 1992 to 2002. Data collected included site of leak, surgical approach, and any recurrence of leak. RESULTS: Fifty-seven CSF leaks occurred in 53 patients with CSF rhinorrhea originating from the nose or paranasal sinuses. Twenty-eight of the 53 had iatrogenic injuries resulting in CSF rhinorrhea, 16 had leaks from trauma, and 13 developed spontaneous CSF leaks. Ten patients responded to nonoperative management with bed rest with or without lumbar drain placement. Forty-three patients with 47 leaks underwent surgical repair of CSF rhinorrhea, of which 38 resolved after initial repair. Five of these patients developed recurrent CSF leaks at the repair site but resolved with subsequent surgery. Of these, two initially presented with spontaneous CSF leaks, one patient had a gunshot wound with massive skull base injury, and two recurred after repair of an iatrogenic injury. Factors associated with failure included lateral sphenoid leaks and elevated body mass index (BMI). DISCUSSION: Multiple approaches to the management of CSF rhinorrhea can be successful. An endoscopic repair results in resolution of CSF rhinorrhea in the majority of cases. Patients with spontaneous CSF rhinorrhea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases.     

Endonasal endoscopic repair of cerebrospinal fluid leaks of the sphenoid sinus

BACKGROUND: Multiple reports have demonstrated the efficacy of the transnasal endoscopic repair of cerebrospinal fluid (CSF) leaks of the anterior cranial base. The literature, however, lacks a comprehensive clinical study specifically addressing the transnasal endoscopic repair of CSF leaks of the sphenoid sinus. OBJECTIVE: To ascertain the factors that significantly affect the surgical outcome after transnasal endoscopic repair of CSF leaks of the sphenoid sinus. METHODS: We retrospectively reviewed the medical records of all patients who underwent an endoscopic transnasal repair of CSF leaks of the sphenoid sinus at our teaching hospitals. RESULTS: Twenty-four patients with CSF leaks of the sphenoid sinuses that were repaired by the transnasal endoscopic approach were included in our study. Causes of the CSF leaks included trauma, surgery, neoplasms, and idiopathic causes. Obliteration was the most common technique used to repair the CSF fistulas (used in 15 [58%] of 26 procedures). Grafting materials included banked pericardium, mucosa, turbinate bone, and mucoperichondrium placed by underlay or onlay grafting or abdominal fat used to obliterate the sphenoid sinus. Twenty-two patients were successfully treated on the first attempt. A persistent leak in 2 patients with previously unrecognized high-pressure hydrocephalus was repaired during a second endoscopic surgery, quickly followed by ventriculoperitoneal shunting. CONCLUSIONS: Assuming an adequate repair, other factors such as the cause, the size of the defect, the technique and material used to repair the defect, and perioperative management do not affect the surgical outcome significantly. Untreated high-pressure hydrocephalus can lead to a recurrence or persistence of the leaks and should be suspected in patients with posttraumatic, idiopathic, or recurrent CSF leaks.     

A case of sphenoid sinus meningoencephalocele repaired by an image-guided endoscopic endonasal approach

We report a Japanese patient with a complaint of unilateral watery nasal discharge. Analysis of the nasal discharge showed it to contain high levels of sugar and transferrin, which indicated cerebrospinal fluid (CSF) rhinorrhea. A diagnosis of sphenoid sinus meningoencephalocele was easily made on the basis of the CT, MRI and nasal discharge findings. We performed surgery by an image-guided endoscopic endonasal approach (IGEEA). An image guidance system (IGS) was used to confirm the position of the bone defect and the prolapsed brain lobe. We resected the brain lobe, and used fat tissue and fascia to create an extracranial-intracranial blockade. As of 18 months after the operation, there is no evidence of infection or CSF leakage. The IGEEA enabled us to successfully repair the middle skull base using a multi-layer sealing technique, while the IGS allowed us to confirm the anatomical structures and successfully avoid causing collateral damage to the surrounding tissues. This case exemplifies the beneficial effect that of the development of surgical support equipment on the operative approach that is now indicated for sphenoid sinus meningoencephaloceles: the endonasal approach has largely replaced other approaches, such as lateral rhinotomy.     

Endoscopic repair of cerebrospinal fluid rhinorrhea — Manipal experience

Otolaryngologists play a major role in the management of cerebrospinal fluid (CSF) rhinorrhea. A thorough understanding of the underlying pathophysiology and the various treatment options available is essential to achieve the best possible results. In this paper, we are highlighting the pathophysiology, diagnosis and surgical technique involved in the repair of cerebrospinal fluid rhinorrhea. A retrospective study conducted in the department of ENT and Head and Neck Surgery, Kasturba Hospital, Manipal is presented to highlight our experience with cerebrospinal fluid rhinorrhea. Eleven patients were managed in the department of otolaryngology between 1999 and 2005. Seven had spontaneous CSF rhinorrhea, three were due to trauma and one iatrogenic, following surgery. Commonest anatomic site of leak was the cribriform plate in 4 cases. Other sites included sphenoid [2], lateral lamella [2], fovea ethmoidalis [2] and olfactory groove [1]. Onlay technique was performed in 10 out of 11 patients. Closure was successful in 10 out of 11 cases in the first attempt. One patient underwent revision surgery. Patients were followed up for a period ranging from 3 months to 3 years. CSF rhinorrhea is a potentially fatal condition which requires precise and urgent treatment. The transnasal endoscopic repair of CSF leak has a high success rate with low morbidity when performed by experienced endoscopic sinus surgeons. Our experience in managing this condition is presented.     

Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea

The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery. The clear anatomical exposure of the roof of the nasal and paranasal sinus cavities by the endoscope offers the surgeon a golden chance to identify the area of CSF leak, and thus enables one to adequately plan the management. The aim of this work is to evaluate the use of facia lata sandwich graft technique for endoscopic endonasal repair of CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were treated endoscopically using 2 layers of facia lata (underlay and onlay) interposed with a layer of septal cartilage or conchal bone in-between (sandwich technique) for repair. Fifty-five percent of cases were regarded as spontaneous CSF leaks with no obvious cause, 30 % following head injury and 15 % were iatrogenic. The ethmoidal roof was the commonest location of CSF leak (60 %) followed in frequency by the cribriform plate and the sphenoid sinus (20 % each). Follow-up period was 12–24 months. We have achieved a 95 % success rate in managing CSF leaks in our 40 patients in the first attempt repair and 100 % success rate after second attempt repair. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high success rate and avoid the morbidity associated with craniotomy. Using the three-layer, sandwich-grafting technique of facia lata further adds more security to the sealing of CSF and augments the results of repair.     

自发性脑脊液鼻漏定位诊断的影像学征象分析

目的 通过总结自发性脑脊液鼻漏患者的影像学直接征象和间接征象,为脑脊液鼻漏修补术前瘘点的影像学定位诊断提供依据。方法 回顾性分析2017年1月—2021年3月中南大学湘雅医院耳鼻咽喉头颈外科诊治的48例患者的临床资料,所有患者术前行鼻窦颅底高分辨CT(HRCT)和核磁共振(MRI)水成像检查。术前分析其影像学直接征象和间接征象,并结合术中情况证实其瘘点位置。结果 48例患者术前经影像学瘘点判断并经手术证实瘘点位于筛板20例(41.7%),蝶窦外侧隐窝16例(33.3%),筛顶8例(16.7%),额窦后壁2例(4.2%),斜坡2例(4.2%)。研究发现不同区域的自发性脑脊液鼻漏直接征象和间接征象存在明显不同,间接征象如左右侧不对称,引流通道水肿,窦腔黏膜增厚和积液征可以用于寻找瘘点。瘘口在影像学上根据直接征象颅底骨质缺损的诊断符合率为66.7%,而联合应用CT与MRI水成像根据直接征象和间接征象联合应用的诊断符合率为100%。结论 自发性脑脊液鼻漏患者影像学的间接征象对于术前准确判断瘘点具有重要价值。     

Exploration of endonasal endoscopic repair of pediatric cerebrospinal fluid rhinorrhea

Objectives

To summarize the clinical manifestations of pediatric cerebrospinal fluid rhinorrhea (CSFR), discuss the localization of CSFR, and the surgical approaches, the graft material selection and the prognoses of endoscopic repair of CSFR.

Methods

The case data, surgical techniques and graft materials of endonasal endoscopic approach of 43 patients with CSFR who have been treated at the Second Xiangya Hospital, Central South University in the last 13 years were retrospectively analyzed. Among them, leaks in 34 cases were from the roof of the ethmoid sinuses. Other sites included frontal sinus (1), sphenoid sinus (6), and the conjunction of ethmoid and frontal sinuses (2). 37 patients were with unilateral CSF leaks, 6 were with bilateral CSF leaks. The dimensions of the defects ranged between 8 and 22 mm. For 25 cases, the procedure was as follows: first, the wound surrounding the perimeter of the defect was freshened and the leaks were plugged by myoplasm and overlaid with iliac fascia, and followed by the use of fibrin glue and nasal packing; for 5 cases, the procedure was as follows: at first, the wound was curetted and the leaks were intracranially plugged by autologous cartilage and muscle, overlaid with iliac fascia, followed by the use of fibrin glue and nasal packing; for 6 cases, the leaks were overlaid with iliac fascia only, and then fibrin and packing were used. For the rest of 7 cases, the frontal and sphenoid sinuses were filled with muscle.

Results

Of the total 43 cases, 31 had successful closure of the leaks by endonasal endoscopic repair on first attempt; 8 had successful closure of the leaks on second attempt, 3 was cured on third attempt; while, leaks in 2 patients failed to close after three attempts. Therefore, they underwent combined intracranial and transnasal endoscopic repair, one patient was cured and another one died postoperatively because of recurrent intracranial infection. At 12 month to 24 month follow-up 42 children remained leak free.

Conclusion

Endoscopic repair of CSF leaks is the optimum approach to the treatment of pediatric CSFR, featuring minor trauma, high successful rate, fewer complications and advantage of being able to carry out a revision surgery or more if needed. For children who have a large CSF leak in size and have failed to be treated successfully via endonasal endoscopic repair, combined intracranial and endoscopic repair could be performed to close the leak.     

Acellular dermal allograft for sellar reconstruction after transsphenoidal hypophysectomy

Obliteration of the sphenoid sinus using fat is often used after transsphenoidal hypophysectomy. The morbidity of this approach includes donor site complications, fat necrosis, and delayed mucocele formation. As obliteration with fat is intended to prevent cerebrospinal fluid (CSF) leakage, an alternative for this technique would be techniques used for CSF rhinorrhea repair. Instead of sinus obliteration, these defects are repaired with fascial autografts, which are unfortunately associated with donor site complications. To avoid sinus obliteration and donor site complications, we have reconstructed the sella with acellular dermal allograft in lieu of sinus obliteration. Transsphenoidal hypophysectomy was performed under combined microscopic and endoscopic visualization. For closure, the sellar anterior wall was reconstructed with acellular dermal allograft, septal cartilage/bone autograft, and fibrin glue. The sinus mucosa was then draped over the reconstruction and held in place with microfibrillar collagen hemostat slurry. The sphenoid sinus was not obliterated. Postoperatively, all patients underwent serial nasal endoscopy. Thirteen patients underwent the procedure as described for removal of pituitary adenoma. Postoperative discomfort and pain were minimal. Intraoperative CSF leaks were identified in five patients; none of these patients experienced a postoperative CSF leak. The microfibrillar collagen hemostat was cleared by sphenoid mucociliary clearance. One patient developed acute sphenoid sinusitis several weeks after surgery; this patient did not develop meningitis. One postoperative CSF leak occurred in an obese patient, in whom an intraoperative CSF leak was not identified; this leak resolved with bedrest and delayed lumbar drainage alone. Sellar reconstruction with acellular dermal allograft may eliminate the need for sphenoid sinus obliteration after transsphenoidal hypophysectomy. Acellular dermal allograft sellar reconstruction ultimately provides for an aerated, functioning sphenoid sinus without increased CSF leak risk or potential donor site morbidity.     

Endoscopic management of cerebrospinal fluid rhinorrhea

PURPOSE: Most anterior skull base defects causing cerebrospinal fluid (CSF) rhinorrhea can be readily approached using endoscopic techniques when surgical repair is necessary. We present our data from endoscopic repair of CSF rhinorrhea with long-term follow-up. METHODS: Retrospective data analysis of patients that were diagnosed with anterior skull base CSF rhinorrhea and underwent endoscopic repair at a tertiary institution. Data were analyzed to determine the etiology and location of CSF leaks. Diagnostic techniques, surgical techniques, and surgical outcomes were reviewed. RESULTS: Ninety-two patients were diagnosed with CSF rhinorrhea and underwent endoscopic repair over a 12-year period. Forty-eight were males, and 44 were females. The average age was 49 (range 6-81) years. Average follow-up was 25 months, with a range of 12 to 82 months. The etiology of CSF leak was prior endoscopic sinus surgery in 23 patients (25%), idiopathic in 19 (21%), neurosurgery in 17 (18%), trauma in 18 (20%), and the presence of meningocele/encephalocele in 11 patients (12%). The most common location of the defect was the sphenoid sinus (n = 36, 39%), followed by ethmoid roof (n-27, 29%), and cribriform plate (n = 24, 26%). Endoscopic repair was initially successful in 78 (85%) patients. Seven additional patients underwent successful revision endoscopic repair for an overall success rate of 92% (n = 85). Five (6%) large skull base defects were eventually repaired by neurosurgery using open intracranial techniques. No major complications were encountered. CONCLUSION: The intranasal endoscopic approach is an effective and safe technique in the surgical management of anterior skull base CSF rhinorrhea. Long-term success rate in our patient population was 92%.     

Sphenoethmoid cerebrospinal fluid leak repair with hydroxyapatite cement

Despite advances in neurological, reconstructive, and endoscopic sinus surgery, sphenoethmoid cerebrospinal fluid (CSF) fistulae continually pose difficult management problems. Standard surgical techniques for fistulae closure succeed approximately 78% to 90% of the time. To improve this success rate, hydroxyapatite cement (HAC), a Food and Drug Administration-approved substance for cranial defect repair, was applied to this problem in a clinical setting. Twenty-one patients with spontaneous, posttraumatic, or postoperative CSF leaks of the sphenoid sinus, cribriform plate, or ethmoid region were treated with HAC. Study participants were prospectively accrued at 5 tertiary care medical centers in the eastern United States. The CSF leaks of all 21 patients treated with HAC were successfully sealed by its initial application. The sites of CSF leakage included the nasal cavity (n = 2) and sphenoid sinus (n = 19). Fifteen of the patients had previously undergone a failed repair by standard methods. There have been no recurrent CSF leaks with a maximum follow-up of 72 months, and an average follow-up of 36 months. All patients have survived to date. The only HAC-related morbidity was the extrusion of the HAC when placed in the nasal cavity. Hydroxyapatite cement is an effective method of repair for postoperative, posttraumatic, and spontaneous sphenoid CSF leaks. The efficacy of HAC in sealing the CSF leak was unaffected by previous attempts at leak closure by standard methods or by its origin. Hydroxyapatite cement should not be applied transnasally for the treatment of an ethmoid region fistula owing to its high probability of extrusion. Correct patient selection and technical familiarity with HAC are necessary for successful application.     

经鼻内镜额窦脑脊液鼻漏修补术初探

目的探索额窦脑脊液鼻漏修补术的进路、修补方法和手术技巧。方法对9例额窦后壁和4例额隐窝后外侧壁脑脊液鼻漏患者进行手术修补，其中首次手术行鼻内镜下修补术12例，联合进路1例；术后观察手术疗效及并发症情况。结果13例患者中12例一次修补成功，1例二次修补成功。出现并发症2例，其中1例为术后颅内感染，行鼻外引流、额窦填塞术治愈；另1例为阻塞性额窦囊肿，行鼻内镜下额窦开放术治愈。结论经鼻内镜可以成功修补可视的额窦后壁脑脊液鼻漏，但要注意额窦口及漏口大小，防止术后额窦阻塞，诱发阻塞性额窦囊肿、额窦炎和颅内感染；对于额窦内不可视的脑脊液鼻漏和额窦口扩大困难的病例，建议行联合进路修补术。     

Cerebrospinal fluid leakage after gamma knife radiosurgery for skull base metastasis from renal cell carcinoma: a case report

We report a rare case of cerebrospinal fluid (CSF) leakage after radiosurgery for skull base metastasis from renal cell carcinoma. A mass invading the left petrous bone and sphenoid sinus was treated with gamma knife radiosurgery, and CSF rhinorrhea developed 4 months after the procedure. The CSF leak was successfully controlled by endoscopic sinus surgery. CSF leakage may develop as a rare complication after radiosurgery for skull base lesions, and the endoscopic repair technique is a useful therapeutic method.     

外伤性迟发性脑脊液鼻漏的诊断和治疗

目的 探讨外伤性迟发性脑脊液鼻漏的发病原因及临床诊治特点.方法 回顾性分析中山大学附属第一医院院2000-2008年收治的13例外伤≥3个月后出现脑脊液鼻漏患者的临床资料,重点分析术前CT及MRI扫描的结果 ,结合术中所见,分析两者之间的关系.结果 13例患者颅底均有陈旧性骨折,MRI扫描显示其中11例有软组织自颅底缺损处疝入鼻窦.术中鼻内镜检查见骨质缺损最小约为0.1 cm×0.2 cm;最大约为1.2 cm×1.5 cm,漏口部位与CT检查结果 一致,其中11例漏口处可见暴露的硬脑膜及坏死组织.所有病例均采用经鼻内镜下脑脊液鼻漏修补术,术后随访12～36个月,未见复发.结论 脑膜组织经颅底缺损疝入鼻窦为外伤后脑脊液鼻漏迟发的关键因素,CT、MRI检查有助于明确漏口位置,其治疗宜采用鼻内镜下脑脊液鼻漏修补术.     

Reconstruction of a skull base defect after endoscopic endonasal resection of a pituitary adenoma: Sphenoid mucosal flaps

This report describes a bilateral sphenoid sinus mucosal flap for the repair of a sellar floor defect and CSF leak following endoscopic endonasal skull base surgery. The key advantage of this technique is enabling the sphenoid mucosal flaps to remain vascularized, which reduces postoperative complications including CSF leakage, recurrent sinusitis, meningitis, encephalitis and pneumocephalus. The use of this technique is a viable and possibly favorable alternative to free grafts in the reconstruction of small to medium sized sellar defects with low flow or absent CSF leaks base surgery.     

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.     

Identification of intranasal cerebrospinal fluid leaks by topical application with fluorescein dye

The purpose of this paper is to describe a safe new technique for intraoperative identification of the site of cerebrospinal fluid rhinorrhea. Cerebrospinal fluid (CSF) rhinorrhea after intracranial or intranasal surgery is a known potential complication with significant morbidity and mortality. It is currently accepted that endoscopic intranasal management of CSF rhinorrhea is the preferred method of surgical repair, with higher success rates and less morbidity than intracranial surgical repair in selected cases. Accurate identification of the site of CSF leakage is necessary for a successful endoscopic surgical repair. Computer tomography (CT) with or without intrathecal contrast and preoperative nasal endoscopy are frequently used to preoperatively localize the site of the leak. Intrathecal fluorescein administered immediately before surgery has aided in the intraoperative identification of the site of CSF leak in 25-64% of patients undergoing endoscopic repair of CSF rhinorrhea in whom preoperative CT scanning and nasal endoscopy had not identified the site of CSF leak. Intrathecal fluorescein, however, has been associated with severe complications, such as lower extremity weakness, numbness, generalized seizures, opisthotonus, and cranial nerve deficits. We present three cases of CSF rhinorrhea in which fluorescein was applied intranasally during the endoscopic surgical repair. Ten percent fluorescein was applied to the nose with a cotton swab. Under endoscopic visualization the fluorescein changed its fluorescent color from amber/yellow to a dark green and was found streaming from high in the nasal cavity, which led to accurate identification of the site of the CSF leak.     

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.