Subcranial resection of malignant tumors infiltrating the anterior skull base

BACKGROUND: Survival and quality of life after subcranial resection of malignant tumors infiltrating the anterior skull base should be evaluated. METHODS: Data were acquired retrospectively from patient charts and by telephone interview. Quality of life was assessed with the EORTC QLQ30 and H&N35 modules. RESULTS: From 1996 to 2004, 19 patients (mean age 52 years, 4 woman, 15 men) were surgically treated via a subcranial approach. Fifteen patients suffered from advanced carcinoma, 3 from advanced esthesioneuroblastoma, and 1 patient had a fibrosarcoma. Fifteen patients received adjuvant radiotherapy. During the mean follow-up period of 44 months (12-109 months), 6 patients died, 1 unrelated to the tumor. The probability to survive 5 years was 50 %, the mean survival time was 72 months. Anosmia was reported by 18 of 19 patients. A tension pneumocephalus was observed in 2 patients, one with lethal outcome, decreased vision in 1 patient, loss of vision in 1, persisting diplopia in 1, deep wound infections in 2, and CSF leak in 2 patients. Quality of life was assessed on the average 36 months following end of therapy and did not differ substantially from other patients with head-neck malignancies. CONCLUSION: Most, malignant tumors infiltrating the anterior skull base can be treated curatively. The treatment outcome is well comparable to other head and neck tumors of corresponding stage.     

Radial forearm free tissue transfer in the management of persistent cerebrospinal fluid leaks

OBJECTIVE: Cerebrospinal fluid (CSF) leaks can occur after head trauma or skull base surgery. Persistent or spontaneous leaks should be repaired, since they put patients at risk for serious intracranial complications. Although numerous repair methods have been successful, the occasional patient develops a persistent leak. We describe our experience with free tissue transfer for repair of recalcitrant CSF leaks. STUDY DESIGN: Retrospective chart review of patients undergoing free tissue transfer for repair of a CSF leak between November 1995 and October 2004. Setting was an academic, tertiary care referral center. METHODS: Twelve patients with persistent CSF leak were studied. Eleven of 12 patients had undergone a previous repair attempt ranging from endoscopic repair with fat graft to craniotomy and primary repair of the dural defect. All patients underwent radial forearm free tissue transfer. RESULTS: There were six female and six male patients. Average age was 52.7 years (range, 22-80 y). The most common presenting complaints were intracranial abscess, recurrent meningitis, or pneumocephalus (n=9) and CSF otorrhea or rhinorrhea (n=8). Cause was head trauma (n=6), prior surgery (n=4), cholesteatoma (n=1), or meningoencephalocele (n=1). Eleven of 12 patients failed prior procedures (range, 0-6 procedures; mean, 1.9). Ten flaps were placed in the anterior skull base and two were in the middle or posterior skull base. Radial forearm free tissue transfer resulted in sustained resolution of CSF leakage in all 12 patients. CONCLUSIONS: Free tissue transfer is an efficacious option in the repair of recalcitrant CSF leaks.     

Combined subcranial approaches for excision of complex anterior skull base tumors

OBJECTIVE: To present our method for excision of complex anterior skull base tumors via combinations of the subcranial approach. PATIENTS: Of 120 anterior skull base tumor resections, 41 that included 27 (66%) malignant and 14 (34%) benign lesions were performed via combinations of the subcranial approach. Unilateral or bilateral medial maxillectomy was performed using the subcranial approach alone for 13 tumors infiltrating the anterior skull base, ethmoid bones, and medial maxillary wall. A combined subcranial-transfacial approach in 2 lesions or a combined subcranial-midfacial degloving approach in 14 lesions was performed for tumors involving the skull base and the lower or lateral segments of the maxilla. A combined subcranial-transorbital or transfacial-transorbital approach was used for 5 tumors invading the orbit. An extended subcranial-orbitozygomatic approach was used for 6 tumors invading the middle cranial fossa or involving the cavernous sinus. A combined subcranial-Le Fort I down-fracture approach was used for 1 dedifferentiated chordoma invading the anterior skull base and lower clivus. The surgical results, patient quality of life, survival, and complications were measured. RESULTS: Thirty-seven of 41 tumors (90%) were completely resected. Fifteen patients (35.5%) had perioperative complications. There were no postoperative deaths. Two-year overall and disease-free survival in patients with malignant tumors who underwent combined approaches was 66% and 60%, respectively. There was no significant difference in the quality of life between patients operated on via combined or classic subcranial approaches. CONCLUSION: Combinations and modifications of the subcranial approach for excision of complex anterior skull base tumors yield surgical results, survival, quality of life, and complications similar to those found with the classic subcranial technique.     

Closure of cerebrospinal fluid leaks prevents ascending bacterial meningitis

INTRODUCTION: Endoscopic surgery of the anterior skull base has become the standard procedure for the repair of cerebrospinal fluid (CSF) leaks of various origins. Closure of the leaks is believed to prevent ascending meningitis, although no report has specifically shown this. MATERIAL AND METHODS: Retrospective chart study of 39 patients who underwent endoscopic skull base surgery from 1/1993 to 11/2002. SETTING: Tertiary University Hospitals. OUTCOME MEASUREMENT: Incidence of ascending meningitis after endoscopic skull base repair in patients with anterior skull base defects associated or not with meningitis and CSF leak. RESULTS: Forty-one endoscopic repairs of anterior skull base defects of various origins were performed in 39 patients. Fifteen (36.5%) had suffered bacterial meningitis before surgery. Mean follow-up was 65 months (range 22-120). The defect was repaired using an "underlay" technique with lyophilized dura (n=11) or fascia lata (n=30), and covered with free mucosal grafts from either the middle or the inferior turbinates. Closure was achieved in 40/41 cases at first attempt. No recurrence of ascending bacterial meningitis was observed during follow-up in any of the fifteen patients who had previously presented with a CSF leak or skull base defect with meningitis. Also, no new bacterial meningitis occurred in all other patients. One case of meningoencephalocele of the lateral sphenoid wall developed a recurrent CSF fistula associated with bacterial meningitis two years after endoscopic repair, requiring endoscopic revision surgery. No patient received vaccination in this series. DISCUSSION: Closure of active CSF leaks and reconstruction of skull base defects without CSF-leak in patients with prior ascending bacterial meningitis seem to provide excellent long-term results with neither recurrence of ascending meningitis nor incidence of meningitis in the other patients, unless a CSF leak re-appears. Conservative treatment of CSF leaks may lead to bacterial meningitis, therefore surgical closure of leaks or defects at the skull base should be considered treatment of choice to prevent ascending meningitis.     

The bath-plug closure of anterior skull base cerebrospinal fluid leaks

BACKGROUND: This study presents the technique and results of cerebrospinal fluid (CSF) leak closure by placement of a fat plug on the intracranial surface of the dura. A prospective cohort study of all consecutive patients undergoing endoscopic closure of an anterior skull base CSF leak using the bath-plug technique was performed at a tertiary care center. METHODS: Thirty-three patients presented with CSF leaks: 6 were traumatic, 7 were spontaneous, 9 were iatrogenic, and 10 were associated with a meningoencephalocele. The average age of the patients was 40 years and the male-to-female ratio was 1.2:1. All patients underwent the bath-plug technique for closure of CSF leaks. The surgical technique was presented. RESULTS: Thirty-one of the 33 patients had a successful primary closure of their CSF leak with 2 patients requiring a repeat procedure. After an average of 28 months follow-up, there were no recurrent leaks in any of the patients. This gives a primary closure success rate of 94% and a secondary closure rate of 100%. CONCLUSION: The bath-plug technique for closure of anterior skull base CSF leaks was a reliable technique for a large variety of causes.     

A rational approach to the use of tracheotomy in surgery of the anterior skull base

OBJECTIVE: To offer an algorithm for airway management in anterior skull base surgery. METHODS: This is a retrospective review of 109 patients undergoing major anterior skull base surgery from a single senior surgeon's experience from September 1997 to May 2006. RESULTS: We report only one (1%) postoperative mortality in this series and only seven major complications in six patients, including two cases of stroke, one case of cerebrospinal fluid (CSF) leak, and four cases of delayed osteoradionecrosis. No patients in this series developed tension pneumocephalus. The total major complication rate is 6%. Fifty-one (47%) patients received prophylactic tracheotomy, and 58 (53%) patients did not receive prophylactic tracheotomy. Eighty-eight (81%) patients received anterior skull base reconstruction with local flaps. Six (5.5%) patients required primary reconstruction with a free flap. CONCLUSION: We attribute the very low rate of major complications in this series and, in particular, no cases of tension pneumocephalus and rarity of CSF leaks primarily to prophylactic tracheotomy in selected patients and to a reconstructive strategy that emphasizes use of local vascularized tissue to reconstruct the anterior skull base.     

Anterior skull base reconstruction after tumour resection using the posterior wall of the frontal sinus

IntroductionThe authors describe their experience of surgical closure of the anterior skull base after tumour resection, using the posterior wall of the frontal sinus.Material and methodThe authors describe their anterior skull base closure technique performed in three patients after tumour resection. Tumour resection via a transglabellar approach resulted in an anterior skull base defect. Reconstruction consisted of direct implantation of the posterior wall of the frontal sinus without using a bone substitute (except when nasofrontal duct obstruction is required).ResultsThree patients were operated by this surgical procedure with complete tumour resection in every case and no infectious complications. This technique was easy to perform, despite one case of persistent CSF leak. Follow-up imaging showed no displacement of the onlay bone graft.ConclusionAnterior skull base reconstruction after tumour resection using autologous frontal sinus bone graft is easy to perform with a low complication rate.     

Three-layer reconstruction for large defects of the anterior skull base

OBJECTIVES: To evaluate and discuss a three-layer rigid reconstruction technique for large anterior skull base defects. STUDY DESIGN: Prospective, nonrandomized, non-blinded. SETTING: Tertiary teaching medical center. METHODS: Twenty consecutive patients underwent craniofacial resection for a variety of pathology. All patients had large anterior cranial base defects involving the cribriform plate, fovea ethmoidalis, and medial portion of the roof of the orbit at least on one side. A few patients had more extensive defects involving both roof of the orbits, planum sphenoidale, and bones of the upper third of the face. The defects were reconstructed with a three-layer technique. A watertight seal was obtained with a pericranial flap separating the neurocranium from the viscerocranium. Rigid support was provided by bone grafts fixed to a titanium mesh, anchored laterally to the orbital roofs. All patients had a computed tomography scan of the skull on the first or second postoperative day. Patients were observed for immediate and long-term postoperative complications after such reconstruction. RESULTS: Postoperative computed tomography scans showed small pneumocephalus in all patients. It resolved spontaneously and did not produce neurologic deficits in any patient. There was no cerebrospinal fluid leak, hematoma, or infection. On long-term follow-up, exposures of bone graft or mesh, brain herniation, or transmission of brain pulsation to the eyes were not observed in any patient. CONCLUSIONS: Three-layer reconstruction using bone grafts, titanium mesh, and pericranial flap provides an alternative technique for repair of large anterior cranial base defects. It is safe and effective, and provides rigid protection to the brain.     

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%.     

Nasoseptal "rescue" flap: a novel modification of the nasoseptal flap technique for pituitary surgery

Objectives:

The introduction of the pedicled nasoseptal flap (NSF) has decreased postoperative cerebrospinal fluid (CSF) leak rates from >20% to <5% during expanded endoscopic skull base surgery. The NSF must be raised at the beginning of the operation to protect the posterior pedicle during the expanded sphenoidotomy. However, in most pituitary tumor cases, an intraoperative CSF leak is not expected but at times encountered. In these cases, a “rescue” flap approach can be used, which consists of partially harvesting the most superior and posterior aspect of the flap to protect its pedicle and provide access to the sphenoid face during the approach. The rescue flap can be fully harvested at the end of the case if the resultant defect is larger than expected, or if an unexpected CSF leak develops. This technique minimized septum donor site morbidity for those patients without intraoperative CSF leaks.

Results:

The rescue flap technique allows for binaural and bimanual access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. If an intraoperative CSF leak is encountered, the rescue flap is then converted into a normal nasoseptal flap for skull base reconstruction. If no leak is obtained, then the patient does not suffer additional donor site morbidity from the full flap harvest.

Conclusions:

This new technique allows for sellar tumor removal prior to the nasoseptal harvest, thereby eliminating donor site morbidity for those pituitary tumor patients who do not have an intraoperative CSF leak.     

Algorithm for reconstruction after endoscopic pituitary and skull base surgery

INTRODUCTION: The expanding role of endoscopic skull base surgery necessitates a thorough understanding of the indications, techniques, and limitations of the various approaches to reconstruction. The technique and outcomes of endoscopic skull base reconstruction remain incompletely described in the literature. STUDY DESIGN AND METHODS: Patients undergoing endoscopic skull base surgery underwent an algorithmic approach to reconstruction based on tumor location, defect size, and presence of intraoperative cerebrospinal fluid (CSF) leak. A prospective database was reviewed to determine the overall efficacy of reconstruction and to identify risk factors for postoperative CSF leak. RESULTS: The diagnosis in the 127 patients in this series included pituitary tumor in 70 (55%) patients, encephalocele in 16 (12.6%) patients, meningioma in 11 (8.7%) patients, craniopharyngioma in 9 (7.1%) patients, and chordoma in 6 (4.7%) patients. Successful reconstruction was initially achieved in 91.3% of patients. Eleven (8.7%) patients experienced postoperative CSF leak, 10 of which resolved with lumbar drainage alone. One (0.8%) patient required revision surgery. Correlation between postoperative CSF leak and study variables revealed a statistically significant longer duration of surgery (243 vs. 178 min, P = .008) and hospitalization (12.1 vs. 4.5 days, P < .0001) and a trend toward larger tumors (mean, 3.2 vs. 2.3 cm; P = .058) in patients experiencing postoperative CSF leak. CONCLUSION: The algorithm for reconstruction after endoscopic surgery presented in this study is associated with excellent overall efficacy. A greater understanding of risk factors for postoperative CSF leak is imperative to achieve optimal results.     

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.     

Spontaneous CSF rhinorrhoea from separate defects of the anterior and middle cranial fossa

Multiple congenital dehiscence of the skull base is rare and can give rise to spontaneous CSF rhinorrhoea. A search of the world literature revealed only five reports of CSF leak with more than one concomitant skull base defect. When treating a patient with spontaneous CSF rhinorrhoea the possibility of its originating from the middle ear and eustachian tube should be considered. An intrathecal injection of fluorescein is useful in establishing the site of a CSF leak especially when a computed tomography scan (CT) or magnetic resonance image (MRI) has not localized the site. We discuss a case of a 72-year-old lady presenting with CSF rhinorrhoea, who had an anterior skull base defect localized with the help of intrathecal fluorescein and repaired surgically. Subsequent to this she had a further episode of CSF rhinorrhoea that originated from a middle-ear meningocele that was then repaired.     

外伤性颅底骨折致脑脊液漏的发生及处理

目的：探讨脑脊液漏在颅底骨折时的发生率、部位、时间及治疗方法。方法：回顾分析近18年来收治的358例颅底骨折患者的临床资料。结果：脑脊液漏的发生率为24.58%（88／358）。发生于前颅窝56例，中颅窝23例，前中颅窝9例。57例在外伤后48?h内发病，占63.64%，最迟者外伤后28年才发病。88例脑脊液漏中，73例经保守治疗痊愈，11例经一次手术痊愈，3例经二次手术痊愈，1例经三次手术后，因颅内感染呼吸循环衰竭死亡。15例手术治疗中，4例在鼻内窥镜下经鼻行脑脊液漏修补一次成功。结论：颅底骨折部位及脑脊液漏发生时间决定了治疗方案的选择，并与疗效直接相关。鼻内窥镜下手术具有副损伤小，瘘孔定位准确，手术反应轻等优点，值得推广。     

Otogenic tension pneumocephalus caused by therapeutic lumbar CSF drainage for post-traumatic hydrocephalus: a case report

Tension pneumocephalus occurs when a continuous flow of air accumulates in the intracranial cavity and produces a mass effect on the brain. We describe a case in which tension pneumocephalus was caused by the performance of continuous lumbar CSF drainage in a middle-aged man who had experienced a temporal bone fracture. Continuous lumbar CSF drainage is commonly performed in patients with temporal bone or basilar skull fractures to treat concomitant post-traumatic CSF rhinorrhea, CSF otorrhea, and/or hydrocephalus. However; to the best of our knowledge, there has been no previously reported case of tension pneumocephalus occurring as a complication of this procedure in a patient with a temporal bone fracture.     

Early harvesting of the vascularized pedicled nasoseptal flap during endoscopic skull base surgery

Purpose

The vascularized pedicled nasoseptal flap (PNSF) represents a successful option for reconstruction of large skull base defects after expanded endoscopic endonasal approaches (EEA). This vascularized flap can be harvested early or late in the operation depending on the anticipation of high-flow CSF leaks. Each harvesting technique (early vs. late) is associated with different advantages and disadvantages. In this study, we evaluate our experience with early harvesting of the PNSF for repair of large skull base defects after EEA.

Methods

A retrospective review was performed at a tertiary care medical center on patients who underwent early PNSF harvesting during reconstruction of intraoperative high-flow CSF leaks after EEA between December 2008 and March 2012. Demographic data, repair materials, surgical approach, and incidence of PNSF usage were collected.

Results

Eighty-seven patients meeting the inclusion criteria were identified. In 86 procedures (98.9%), the PNSF harvested at the beginning of the operation was used. In 1 case (1.1%), the PNSF was not used because a high-flow intraoperative CSF leak was not encountered. This patient had recurrence of intradural disease 8 months later, and the previously elevated PNSF was subsequent used after tumor resection.

Conclusion

Based on our data, a high-flow CSF leak and need for a PNSF can be accurately anticipated in patients undergoing EEA for skull base lesions. Because of the advantages of early harvesting of the PNSF and the high preoperative predictive value of CSF leak anticipations, this technique represents a feasible harvesting practice for EEA surgeries.     

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.     

Securing the position of the nasoseptal flap in endoscopic transsphenoidal surgery: No need for a Foley catheter (technical report)

BackgroundThe pedicled nasoseptal mucoperiosteal flap is currently widely used for the reconstruction of a skull base defect following transsphenoidal surgery. The flap is generally secured in position by a Foley catheter balloon. We describe an alternative technique using cylinders of Gelfoam™ (Pfizer Incorporated) to buttress the flap in place, obviating the need for a balloon catheter.Material and methodsA review of our database identified patients who underwent endoscopic transsphenoidal surgery for a pituitary macroadenoma with nasoseptal flap, secured with small rolls of Gelfoam™ (Pfizer Incorporated) rather than a nasal Foley catheter. Minimum follow-up clinical and MRI assessments: 3 months.Results73 patients (mean follow-up: 22 months) met the inclusion criteria: 56 non-functioning and 17 functioning pituitary adenomas. 36 patients had an intraoperative CSF leak: 30 high flow and 6 low flow leaks. The surgical repair in 35 patients included fat +/− fascia graft. One patient had a post-operative CSF leak repaired by subsequent surgery without the use of a Foley catheter.ConclusionSecuring the nasoseptal flap using rolls of Gelfoam™ (Pfizer Incorporated) as described can be achieved without the use of a nasal Foley catheter.     

CSF rhinorrhea-feasibility of conservative management in children

Purpose

To study the role of conservative management in CSF rhinorrhea in pediatric population.

Study design

A retrospective study in a tertiary care center.

Methods

Cases with a diagnosis of CSF rhinorrhea discharged after conservative management but required skull base repair for recurrence of CSF rhinorrhea or meningitis were included in the study between periods 2000 and July 2010.

Results

12 cases of CSF rhinorrhea managed were treated conservatively, 7 patients again required rehospitalisation for recurrence of CSF rhinorrhea or meningitis. Male:female ratio was 4:1. The age ranged from 3 years to 14 years. Duration of recurrence of the CSF leak or meningitis varied from 6 to 121 months. Presenting symptoms included headache, rhinorrhea, or recurrent meningitis. The time from the initial injury to surgical exploration ranged from 163 to 3650 days. All patients were under regular follow-up and doing well except one had recurrence of the leak 2 months after surgery requiring revision surgery following which the patient had no recurrence.

Discussion

The management of CSF fistulae is still a matter of debate and there will be a risk of recurrent meningitis on conservative management. Most comprehensive study to date indicates there is a 9.8% annual risk of developing meningitis. Duration of recurrence of the CSF leak or meningitis varied from 6 months to 121 months. The overall incidence of meningitis as a result of skull base defect and CSF leak ranges from 9% to 50% with a reported cumulative risk of 85% in 10 years if no repair is performed. As seen in our series CSF repair can resolve with conservative management but there is a risk of intermittent CSF leak or meningitis due to an incompletely healed or tenuous mucosal regeneration which should be addressed surgically. The patients with traumatic CSF leak who were treated with conservative management alone had a 25-29% risk of subsequent meningitis.

Conclusion

Conservative treatment of CSF leaks may lead to recurrent meningitis or leaks, therefore surgical closure of defects at the skull base should be considered treatment of choice to prevent ascending meningitis.