Fluoroscopy-Assisted Transnasal Onyx Occlusion of the Eustachian Tube for Lateral Skull Base Cerebrospinal Fluid Leak Repair

Objectives To describe transnasal Eustachian tube (ET) occlusion with a liquid embolic solution for lateral skull base cerebrospinal fluid (CSF) leaks. Design A lateral skull base CSF fistula model was developed by the authors using fresh cadaveric heads. Using a transtympanic needle, regulated pressurized pigmented saline was continuously instilled into the middle ear space and visualized endoscopically in the nasopharynx. An angioembolization catheter was then placed through the cartilaginous ET orifice just medial to the bony ET. Under endoscopic and fluoroscopic guidance, a column of liquid embolic agent was deployed into the bony ET segment up to the middle ear space. Setting Tertiary care academic center. Participants Cadaveric specimens. Main Outcome Measures Cessation of CSF flow after occlusion at supraphysiologic pressures. Results In two cadavers, a CSF fistula model was developed and endoscopic visualization of irrigant flow into the nasopharynx was confirmed. Fluoroscopy provided adequate anatomic views of the ET and middle ear, in addition to dynamic views of embolization. Cessation of flow after occlusion was successfully achieved with pressures up to 25 mm Hg, which exceeds normal physiological intracranial pressure. Conclusion Eustachian tube occlusion with a liquid embolic solution is feasible in a novel cadaveric CSF leak model. In the future, this relatively short, straightforward procedure may become an outpatient alternative to manage intermittent or low-flow CSF fistulae following lateral skull base surgery.

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Managing Cerebrospinal Fluid Rhinorrhea after Lateral Skull Base Surgery via Endoscopic Endonasal Eustachian Tube Closure

American Journal of Rhinology and Allergy ◽

10.2500/ajra.2015.29.4146 ◽

2015 ◽

Vol 29 (3) ◽

pp. 207-210 ◽

Cited By ~ 6

Author(s):

Lori A. Lemonnier ◽

Belachew Tessema ◽

Arjuna B. Kuperan ◽

Deya N. Jourdy ◽

Fred F. Telischi ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Eustachian Tube ◽

Skull Base Surgery ◽

Endoscopic Endonasal ◽

Cerebrospinal Fluid Rhinorrhea ◽

Lateral Skull Base ◽

Tube Closure

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Audiometric Outcomes and Middle Ear Disease following Cerebrospinal Fluid Leak Repair

Otolaryngology ◽

10.1177/0194599820911720 ◽

2020 ◽

Vol 162 (6) ◽

pp. 942-949

Author(s):

Kristen L. Yancey ◽

Nauman F. Manzoor ◽

David S. Haynes ◽

Marc L. Bennett ◽

Matthew O’Malley ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Middle Ear ◽

Cerebrospinal Fluid Leak ◽

Ossicular Chain ◽

Middle Cranial Fossa ◽

Lateral Skull Base ◽

Increase Risk ◽

Ossicular Chain Reconstruction ◽

Csf Leaks

Objective To investigate audiometric outcomes and incidence of chronic ear disease following lateral skull base repair (LSBR) of cerebrospinal fluid (CSF) leaks. Study Design Retrospective review. Setting Tertiary skull base center. Subjects and Methods Consecutive adults undergoing LSBR of CSF leaks between 2012 and 2018 were reviewed. Audiometric data included mean air conduction pure-tone average (PTA), air-bone gap (ABG), speech recognition threshold (SRT), and word recognition score (WRS). The incidence and management of the following were collected: effusion, retraction, otitis media and externa, perforation, and cholesteatoma. Results Seventy-three patients underwent transmastoid (n = 5), middle cranial fossa (n = 2), or combined approach (n = 67) for repair of spontaneous leaks (sCSFLs, n = 41) and those occurring in the setting of chronic ear disease (ceCSFLs, n = 32). ABG decreased 7.23 dB ( P = .01) in sCSFL patients. Perforations ( P = .01) were more likely in ceCSFL. No sCSFL patient developed a cholesteatoma, perforation, or infection. Effusions (n = 7) were transient, and retractions (n = 2) were managed conservatively in the sCSFL cohort. Eight ceCSFL patients required tubes, 3 underwent tympanoplasties with (n = 2) and without (n = 1) ossicular chain reconstruction (OCR), and 1 had tympanomastoidectomy with OCR. Conclusion Lateral skull base repair of CSF leaks maintained or improved hearing. Patients with preexisting chronic ear disease were more likely to require additional intervention to sustain adequate middle ear aeration compared to the sCSFL cohort. LSBR of sCSFL does not appear to increase risk for developing chronic ear disease.

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Spontaneous Congenital Perilabyrinthine Cerebrospinal Fluid Fistulas

Annals of Otology Rhinology & Laryngology ◽

10.1177/00034894211007242 ◽

2021 ◽

pp. 000348942110072

Author(s):

Benjamin D. Lovin ◽

Eric N. Appelbaum ◽

Latifah Makoshi ◽

William E. Whitehead ◽

Alex D. Sweeney

Keyword(s):

Systematic Review ◽

Cerebrospinal Fluid ◽

Intracranial Hypertension ◽

Middle Ear ◽

Jugular Bulb ◽

Csf Leak ◽

Review Of The Literature ◽

Multiple Sources ◽

Lateral Skull Base ◽

Csf Leaks

Objectives: To report a recalcitrant spontaneous cerebrospinal fluid (CSF) fistula arising from multiple, anatomically-linked lateral skull base defects, and to review the available literature to determine optimal techniques for operative repair of congenital CSF fistulae. Methods: A patient with recurrent episodes of otologic meningitis was found to have a patent tympanomeningeal fissure, also known as a Hyrtl’s fissure, and internal auditory canal (IAC) diverticulum that communicated with the jugular bulb. A systematic review of the literature characterized all reports of spontaneous congenital perilabyrinthine CSF leaks, and all cases of Hyrtl’s fissures. Results: An 11-year-old female was referred for recurrent meningitis. Imaging demonstrated a fistulous connection between the middle ear and IAC diverticulum via the jugular foramen. Specifically, a Hyrtl’s fissure was identified, as well as demineralized bone around the jugular bulb. Obliteration of the fissure was initially performed, and a fistula reformed 4 months later. Multifocal CSF egress in the hypotympanum was identified on re-exploration, and middle ear obliteration with external auditory canal (EAC) overclosure was performed. A systematic review of the literature demonstrated 19 cases of spontaneous congenital perilabyrinthine CSF leaks. In total, 6 cases had multiple sources of CSF leak and 2 had history suggestive of intracranial hypertension. All of these noted cases demonstrated leak recurrence. Middle ear obliteration with EAC overclosure was successful in 4 recalcitrant cases. Conclusions: Repair of spontaneous congenital perilabyrinthine CSF leaks in cases demonstrating multiple sources of egress or signs of intracranial hypertension should be approached with caution. Middle ear obliteration with EAC overclosure may provide the most definitive management option for these patients, particularly if initial attempt at primary repair is unsuccessful.

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Cerebrospinal Fluid Leakage from the Lateral Skull Base: Experiences and Proposed Treatment Protocol

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0032-1314259 ◽

2012 ◽

Vol 73 (S 02) ◽

Author(s):

D. Kunst ◽

L. Horstink ◽

B. Verbist

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Treatment Protocol ◽

Cerebrospinal Fluid Leakage ◽

Fluid Leakage ◽

Lateral Skull Base

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795 Trends in Cerebrospinal Fluid Leak Rates Following the Extended Endoscopic Endonasal Approach for Anterior Skull Base Meningioma: A Meta-Analysis Over the Last 20 Years

British Journal of Surgery ◽

10.1093/bjs/znab134.580 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

A H Zamanipoor Najafabadi ◽

D Z Khan ◽

I S Muskens ◽

M L D Broekman ◽

N L Dorward ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Arterial Injury ◽

Gross Total Resection ◽

Csf Leak ◽

Total Resection ◽

Visual Improvement ◽

The Impact ◽

Reconstructive Techniques ◽

Over Time

Abstract Introduction The extended endoscopic approach (EEA) provides direct access for resection of tuberculum sellae (TSM) and olfactory groove meningiomas (OGM) but is associated with cerebrospinal fluid (CSF) leak in up to 25% of patients. To evaluate the impact of improved skull base reconstructive techniques, we assessed published CSF leak percentages in EEA over the last two decades. Method Random-effects meta-analyses were performed for studies published between 2004-2020. Outcomes assessed were CSF leak, gross total resection, visual improvement, intraoperative arterial injury and 30-day mortality. For the main analyses, publications were pragmatically grouped based on publication year in three categories: 2004-2010, 2011-2015, and 2016-2020. Results We included 29 studies describing 540 TSM and 115 OGM patients. CSF leak incidence dropped over time from 22% (95% CI: 6-43%) in studies published between 2004 and 2010, to 16% (95% CI: 11-23%) between 2011 and 2015, and 4% (95% CI: 1-9%) between 2016 and 2020. Outcomes of gross total resection, visual improvement, intraoperative arterial injury, and 30-day mortality remained stable over time Conclusions We report a noticeable decrease in CSF leak over time, which might be attributed to the development of reconstructive techniques (e.g., hadad bassagasteguy flap, and gasket seal), refined multilayer repair protocols, and selected lumbar drain usage.

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Pneumocephalus and CSF leak secondary to skull base fracture by pyrotechnical object: case report

Peruvian Journal of Neurosurgery ◽

10.53668/2021.pjns33175 ◽

2021 ◽

Vol 3 (3) ◽

Author(s):

Marcos Vilca ◽

◽

Carlos Palacios ◽

Sofía Rosas ◽

Ermitaño Bautista ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Pressure ◽

Skull Base ◽

Rare Complication ◽

Cerebrospinal Fluid Leak ◽

Standing Position ◽

Csf Leak ◽

Skull Base Fracture ◽

Timely Diagnosis ◽

The Right

Introduction: Pneumocephalus is mainly associated with traumatic injuries, being a rare complication but with high mortality rates; it behaves like a space-occupying lesion and increases intracranial pressure. The symptoms are not specific, but in the event of trauma it is necessary to suspect this entity to carry out a timely diagnosis and treatment, since being the product of the skull base fracture it can cause communication with the outside, and the appearance of cerebrospinal fluid (CSF) leak. Clinical Case: a 38-year-old male patient who suffers trauma from a pyrotechnic explosion near his right ear, when handling a pyrotechnic object (whistle) during the New Year, presenting severe pain, slight bleeding in the right ear, feeling faint and holocranial headache that increased in a standing position; likewise, he presents high-flow aqueous secretion (CSF) from the right ear. Brain and skull base tomography (CT) showed air in the intracranial cavity, fracture of the skull base, and the ossicles of the right middle ear. Conservative management was performed using rest and lumbar drainage, presenting a satisfactory evolution. Conclusion: Pneumocephalus is a frequent and expected complication of trauma with a skull base fracture. Its early and timely diagnosis using skull base CT is essential to define therapeutic measures. Accidents due to the misuse of pyrotechnics continue to be a relevant problem in our country. Knowing and disseminating its consequences can help raise awareness in the population. Keywords: Pneumocephalus, Skull Base, Intracranial Pressure, Cerebrospinal Fluid Leak. (Source: MeSH NLM)

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Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

Journal of Neurosurgery ◽

10.3171/jns.1999.90.4.0651 ◽

1999 ◽

Vol 90 (4) ◽

pp. 651-655 ◽

Cited By ~ 37

Author(s):

Marc S. Schwartz ◽

James I. Cohen ◽

Toby Meltzer ◽

Michael J. Wheatley ◽

Sean O. McMenomey ◽

...

Keyword(s):

Skull Base ◽

Free Flap ◽

Cranial Base ◽

Csf Leak ◽

Content Type ◽

Lateral Skull Base ◽

Csf Leakage ◽

Radial Forearm ◽

Microvascular Free Flap ◽

Fine Print

Object. Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage.Methods. Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation.Conclusions. Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to “low-volume” defects.

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Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Post-Operative Period Following Pituitary and Ventral Skull Base Surgery

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1722-4433 ◽

2021 ◽

Author(s):

Peter A. Benedict ◽

Joseph R. Connors ◽

Micah R. Timen ◽

Nupur Bhatt ◽

Richard Lebowitz ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Postoperative Period ◽

Skull Base Surgery ◽

Tertiary Care ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Predictive Values ◽

Ventral Skull Base ◽

Csf Leaks

Objective: Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design: Retrospective chart review Setting: Tertiary care center Methods and Participants: All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017–March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intra-operative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures: Specificity and safety of ITF Results: Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50±11.89. There were 6 patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100% and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions: Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. Intrathecal fluorescein represents a specific and safe test with potential utility in the postoperative setting.

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Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1693124 ◽

2019 ◽

Vol 81 (06) ◽

pp. 645-650

Author(s):

Roshni V. Khatiwala ◽

Karthik S. Shastri ◽

Maria Peris-Celda ◽

Tyler Kenning ◽

Carlos D. Pinheiro-Neto

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Fascia Lata ◽

High Flow ◽

Csf Leak ◽

Nasoseptal Flap ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Csf Diversion ◽

Csf Leaks

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

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