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.     

Unusual dural fistulae

The authors present seven cases of dural fistulae selected because of their difficulty in diagnosis or in the approach to treatment. The first case had a "delayed traumatic" CSF rhinorrhea and the diagnosis remained, to the end, presumptive. The second and the third were either "spontaneous" or "delayed traumatic" in origin. One of these fistulae was localized in a lateral recess of the sphenoid sinus. Both were approached through the ethmoid, and one of these had to be re-operated intracranially because of recurrence. The fourth had a congenital meningo-encephalocele. The fifth and sixth had fistulae secondary to fronto-ethmoidal osteomas, one presenting with an intracranial mucocele, the other with a cerebral abscess. The last one, a traumatic fistula had to be treated extracranially after two unsuccessful intracranial approaches.     

Frontobasal fractures in children

In 1987, four children between 5 and 13 years of age with severe frontobasal trauma and dural tears were treated operatively. A CSF rhinorrhea was manifest clinically in only two cases. In addition high-resolution computerised tomography was essential in diagnosis and planning of the operation. In each of the cases an intracranial pneumatocele indicating dural laceration was shown. The fractures were confirmed during surgery in: Case 1. The roof of the ethmoid sinus and the roof of the orbit. Case 2. Both the sphenoid sinuses. Case 3. The roof of the ethmoid sinus and the posterior wall of the frontal sinus. Case 4. The roof of the ethmoidal sinus and the posterior wall of the frontal sinus. The ontogenetically oldest part of the paranasal sinuses in the floor of the anterior cranial fossa forming the anterior part of the roof of the ethmoid bone is the site of predilection for fractures, even in children. The anterior cranial fossa was exposed in each case through a paranasal subfrontal access, in the first case combined with a frontal craniotomy by a neurosurgeon, because of the fracture of the roof of the orbit. In the second case the dural injury had to be closed at a second neurosurgical operation, because of a recurrence of the CSF leak. The third and fourth cases were treated by nasal surgery alone.     

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。     

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。     

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.     

Recurrent meningitis in a child secondary to a parasellar arachnoid cyst: A case report

We report a case of recurrent pneumoccal meningitis in an 8-year-old boy with an underlying congenital cerebrospinal fluid (CSF) fistula of the sphenoid sinus associated with a large parasellar arachnoid cyst. High resolution computed tomography (CT) scan showed no obvious skull base defects. A magnetic resonance imaging (MRI) scan revealed a large parasellar arachnoid cyst. He underwent obliteration of the right sphenoid sinus via an endoscopic transsphenoidal approach. Conclusion: Recurrent bacterial meningitis requires needs to be fully investigated with CT scan and MRI of the brain and skull base. Repair of these skull base defects are mandatory.     

Repair of cerebrospinal rhinorrhea]

The present paper describes a new method for repairing the CSF rhinorrhea from the sella turcica using frontal muscle--galea aponeurotica--periosteum flap with blood vessel pedicle through cranial-nasal approach. This new method possesses the following advantages: short approach, clear field of vision, nose injury, few complications and less cosmetic influence. The flap, led into the sphenoid sinus Via the frontal sinus or the anterior cranial base and nasal roof, Survived and grew well due to its sufficient circulation and strong resistance to infection. For all the five cases described in this paper, among which three had accepted two or three repairs before, the CSF rhinorrhea ceased after only one procedure.     

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%.     

Endonasal endoscopic treatment of parasellar arachnoid cyst: report of a case

A 40-year-old man presented with intractable headache of 5-year duration and a 1-month history of intermittent cerebrospinal fluid (CSF) rhinorrhea. Magnetic resonance imaging showed a cystic lesion with signal characteristics similar to that of CSF. The patient underwent endonasal endoscopic surgery of the sphenoid sinus and the fistula was reinforced with facia, muscle cartilage, and posterior septal flap while performing cystocisternostomy. The postoperative course was uneventfiul CSF leakage stopped, and headache improved. Postoperative imaging revealed total collapse of the cyst cavity. Based on our findings, endonasal endoscopic treatment of the sellar and parasellar arachnoid cysts, if presenting into the sphenoid sinus, could be an acceptable minimally invasive alternative to the conventional modalities.     

Adult spontaneous cerebrospinal fluid otorrhea: diagnosis and management

OBJECTIVE: To describe demographic, radiologic, and surgical features in adult patients with spontaneous cerebrospinal fluid otorrhea (SCSFO). STUDIED: Review was made of office and hospital charts of 21 patients with SCSFO and 2 patients with spontaneous CSF rhinorrhea, all of which were repaired successfully from 1989 to 1998. METHOD: Radiologic examples of the structure responsible for SCSFO and rhinorrhea are used to illustrate the changes essential for diagnosis. RESULTS: The responsible lesion for SCSFO and rhinorrhea in the adult are arachnoid granulations (AG) or villi, which do not reach a venous lumen and are aberrantly distributed in areas of the anterior, middle, and posterior cranial fossae that are in proximity to the middle ear/mastoid space, ethmoid, and sphenoid sinuses. The ages of the 21 patients ranged from 38 to 83 years (mean 63 years) with all but one older than 50 years. The sex ratio was 14 women to 7 men; the CSF leak was right sided in 13 and left sided in 8 patients. Eighteen of the SCSF leaks were located in the middle cranial fossa surface of the temporal bone (TB) while two were on the posterior fossa border of the TB. The middle fossa leaks were managed by craniotomy and repair with fascia, whereas the posterior fossa defects were obliterated by adipose tissue inserted through an intact canal wall mastoidectomy. The most common radiologic finding on computerized tomography (CT) was a soft tissue mass adjacent to a tegmen bone defect. The posterior fossa AG created an erosion of cortical and trabecular bone in the mastoid compartment. Spontaneous CSF rhinorrhea in two patients also radiologically appeared as soft tissue mass adjacent to bone erosion in the sphenoid and ethmoid sinuses. These also represent aberrant AGs, which are responsible for CSF rhinorrhea in later life. CONCLUSIONS: The demographic, radiologic, and pathologic findings in this series of 21 TB and 2 paranasal sinus SCSF leaks support the concept that the responsible lesions are AGs that are aberrantly located adjacent to pneumatized parts of the skull. Because these AGs enlarge with age, they may erode through the bony confines of the TB and sinuses and present as SCSFO or rhinorrhea in middle and old age.     

Endoscopic reconstruction of the anterior skull base in cerebrospinal rhinorrhea

Cerebrospinal rhinorrhea is a discharge of cerebrospinal fluid caused by the break continuity in dura mater and by bone defect in the base of anterior skull base. The pathological connections appear mainly in the regions of the skull base with the weaker bone structure (the roof of the frontal, ethmoid, sphenoid sinus and cribriform plate). The aim of the study was presenting the possibility of the endoscopic-surgical closing the fistula within the ethmoid roof. The E.N.T Department in Poznań treated 5 patients with cerebrospinal rhinorrhea. In four cases, cerebrospinal rhinorrhea was caused by operative trauma. In one case the rhinorrhea could not be established. All patients with traumatic rhinorrhea underwent operation treatment based on covering of the loss in dura mater with a piece of mucous membrane together with perichondrium of nasal septum or lyophilised dura. The material used for the plastic operation was sealed by tissue adhesive. In 2 cases rhinorrhea recurred. Using the endoscopic technique, after the identification the leak of the cerebrospinal fluid within ethmoid roof, the fistula has been reconstructed with use of the adipose tissue and temporal muscle fascia. Both cases led to complete recovery. Easy access, precision and accuracy of performance the surgery, the approach without external incision of the patient, makes the endoscopic technique very valuable method in treating rhinorrhea caused by the loss in ethmoid roof and cribriform plate.     

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.     

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.     

Spontaneous cerebrospinal fluid rhinorrhea as the initial presentation of growth hormone-secreting pituitary adenoma

Patients with acromegaly usually present with characteristic clinical features or comorbidities associated with excess insulinlike growth factor 1 (IGF-1)/growth hormone (GH) or may come to medical attention secondary to mass effects causing visual field distortions. Herein, we report a case of spontaneous cerebrospinal fluid (CSF) rhinorrhea as the presenting symptom of acromegaly. A 68-year-old man presented to an outside facility with a 2-day history of headache associated with nausea, vomiting, dizziness, and clear nasal discharge and underwent 2 attempted repairs of a sphenoid sinus CSF leak. Examination on admission to our hospital was significant for fluctuating level of consciousness. Subsequently, subtle coarse facial features were appreciated. Pituitary function testing showed thyrotropin and gonadotropin deficiencies along with an elevated age- and sex-matched IGF-1 of 285 (normal level, 59-225 ng/mL). Nadir GH during oral glucose tolerance test was 5.5 ng/mL and confirmed the diagnosis of acromegaly. Magnetic resonance imaging showed pneumocephalus, an enlarged sella with an elongated pituitary stalk, and partial erosion of the anterior wall of the sphenoid sinus. A distinct adenoma could not be identified. An endoscopic, transnasal, transsphenoidal exploration and biopsy with multilayered skull base reconstruction were performed. Histologic examination of the biopsy contents was consistent with a GH-producing adenoma. Postoperatively, the patient's fluctuating level of consciousness improved and returned to baseline after his successful skull base repair. During the follow-up period, he had an IGF-1 of 713 ng/mL and started treatment with a somatostatin analogue. To our knowledge, this is the first reported case of a GH-producing pituitary adenoma presenting with spontaneous CSF rhinorrhea. Pituitary adenomas should be considered in the differential diagnosis of patients presenting with spontaneous CSF rhinorrhea with abnormal sellar image, and these patients should undergo a thorough hormonal evaluation.     

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.     

Endoscopic management of cerebrospinal fluid leaks

To examine the diagnosis and treatment of patients with cerebrospinal fluid (CSF) rhinorrhea, a cohort of 36 patients treated between 1993 and 2000 were examined to consider the role of imaging and other diagnostic tests such as the presence of beta-transferrin in nasal secretion. The etiology of the condition was considered and was found to be congenital in 7 patients and acquired in 29 patients of which in 15 patients it was traumatic, in 12 patients it occurred spontaneously, and in 2 patients it was associated with Wegener's granulomatosis. Where it was possible to obtain nasal secretion, beta-transferrin proved a highly sensitive and specific test and imaging included computed tomography (CT), CT cisternography, and magnetic resonance imaging (MRI) of which fine detail coronal CT and MRI proved the most helpful. In six patients neither imaging nor beta-transferrin could be used to confirm the diagnosis in which case intrathecal fluorescein was used. Repair was performed endoscopically in all cases with one exception where the defect was felt to be too large for this technique. Middle turbinate mucosa, cartilage, and fascia were the preferred repair materials in the anterior skull base whereas dermalfat was preferentially used in the sphenoid. The overall success rate for an endoscopic approach was 94% although in three cases a second endoscopic procedure was required to produce closure and external approaches were used in two additional patients. The use of a diagnostic algorithm is helpful in both confirming the presence of CSF rhinorrhea and the optimum approach. In the vast majority of cases an endoscopic repair will be successful and it avoids many of the complications associated with craniotomy, particularly in a young population. Therefore, it is our preferred option, although surgeons must be prepared for alternative procedures should these prove necessary.     

经前颅底扩大硬脑膜外入路在脑脊液鼻漏修补术中的应用

目的探讨延迟性脑脊液鼻漏的修补方法。方法经前颅底扩大硬脑膜外入路,用骨蜡或自体骨片、带蒂骨膜瓣和生物蛋白胶-肌浆进行“三明治”式颅底修补方法,治疗外伤性脑脊液鼻漏15例,侵袭性垂体腺瘤并脑脊液鼻漏1例。结果所有病例均一次修补成功。结论经前颅底扩大硬脑膜外入路修补延迟性脑脊液鼻漏方法可靠,可避免多发漏口的遗漏,特别是对筛窦、蝶窦的混合型脑脊液漏可同时修补。     

Localization and infliction pattern of iatrogenic skull base defects following endoscopic sinus surgery at a teaching hospital

Objective

Aim of this study is to evaluate the incidence, infliction patterns and management of dural injuries with cerebrospinal fluid (CSF) rhinorrhea following endoscopic sinus surgery at a teaching hospital. We present our results of over 14 years of experience from endoscopic repair of CSF rhinorrhea with long-term follow-up.

Methods

A retrospective study was performed by screening 14 years of sinus surgeries for iatrogenically inflicted CSF leaks of the anterior skull base. Obtained data were analyzed to determine the infliction pattern and location of CSF leaks, surgical closure techniques and outcomes. All incidences were further evaluated with regards to the surgeons training status.

Results

144 patients out of 6908 sinus surgeries were diagnosed with CSF rhinorrhea and underwent subsequent surgical repair. 52 patients had iatrogenic CSF leaks with 32 of the defects inflicted by the department's physician personnel. Average follow-up was 62 months, with a range of 10–168 months. The side distribution was 56.3% to the patient's right side and in 40.6% to the patient's left side. 68.7% became apparent during the initial surgery whereas 31.3% only after surgery. The most common defect location was the anterior ethmoid at the attachment of the medial concha base with 43.7%, followed by the junction between the ethmoid and sphenoid sinus with 21.9%, the frontal sinus aditus with 18.7% and the medial ethmoid region with 9.4%. With increasing training status, surgeons were more prone to cause defects at the frontal sinus aditus whereas surgeons with lesser training status caused more defects at the anterior ethmoid at the medial concha base. The posterior ethmoid and sphenoid sinus was equally prone to defects over all stages of surgical training. Initial endoscopic repair was successful in 87.5% of patients and 95% after revision surgery.

Conclusion

The obtained data confirm the safety of the endonasal sinus surgery according to Wigand's technique. The incidence of iatrogenic CSF leaks at a teaching hospital is not higher than at specialized rhinology departments. We observed a distinct pattern of inflicted skull base defects with different hot-spot areas, prone to damage in various stages of the surgeon's status of expertise.     

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.