scholarly journals Minimally invasive endoscopic repair of refractory lateral skull base cerebrospinal fluid rhinorrhea: case report and review of the literature

2018 ◽  
Vol 44 (3) ◽  
pp. E8 ◽  
Author(s):  
Brandon Lucke-Wold ◽  
Erik C. Brown ◽  
Justin S. Cetas ◽  
Aclan Dogan ◽  
Sachin Gupta ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Minimally Invasive ◽  
Skull Base ◽  
Congenital Defects ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Lateral Skull Base ◽  
Csf Diversion ◽  
Csf Leaks

Cerebrospinal fluid (CSF) leaks occur in approximately 10% of patients undergoing a translabyrinthine, retrosigmoid, or middle fossa approach for vestibular schwannoma resection. Cerebrospinal fluid rhinorrhea also results from trauma, neoplasms, and congenital defects. A high degree of difficulty in repair sometimes requires repetitive microsurgical revisions—a rate of 10% of cases is often cited. This can not only lead to morbidity but is also costly and burdensome to the health care system. In this case-based theoretical analysis, the authors summarize the literature regarding endoscopic endonasal techniques to obliterate the eustachian tube (ET) as well as compare endoscopic endonasal versus open approaches for repair. Given the results of their analysis, they recommend endoscopic endonasal ET obliteration (EEETO) as a first- or second-line technique for the repair of CSF rhinorrhea from a lateral skull base source refractory to spontaneous healing and CSF diversion. They present a case in which EEETO resolved refractory CSF rhinorrhea over a 10-month follow-up after CSF diversions, wound reexploration, revised packing of the ET via a lateral microscopic translabyrinthine approach, and the use of a vascularized flap had failed. They further summarize the literature regarding studies that describe various iterations of EEETO. By its minimally invasive nature, EEETO imposes less morbidity as well as less risk to the patient. It can be readily implemented into algorithms once CSF diversion (for example, lumbar drain) has failed, prior to considering open surgery for repair. Additional studies are warranted to further demonstrate the outcome and cost-saving benefits of EEETO as the data until now have been largely empirical yet very hopeful. The summaries and technical notes described in this paper may serve as a resource for those skull base teams faced with similar challenging and otherwise refractory CSF leaks from a lateral skull base source.

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

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.

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

2015 ◽  
Vol 29 (3) ◽  
pp. 207-210 ◽  
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

From research to clinical practice: long-term impact of randomized clinical trial examining the effect of lumbar drains on cerebrospinal fluid leak rates following endonasal skull base surgery.

2021 ◽  
Author(s):  
Philippe Lavigne ◽  
paul gardner ◽  
Eric W Wang ◽  
Carl H. Snyderman
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Controlled Trial ◽  
Posterior Cranial Fossa ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Increased Risk ◽  
Cranial Fossa ◽  
Csf Diversion ◽  
Csf Leaks

Intraoperative cerebrospinal fluid (CSF) leaks are associated with increased risk of post-operative CSF leaks despite multilayered reconstruction with vascularized tissue. A recent randomized controlled trial (RCT) examining the use of peri-operative lumbar drains (LD) in high-risk skull base defects identified a significant reduction in post-operative CSF leak incidence (21.2% vs. 8.2%; p=0.017). This study was conducted to assess the efficacy of the selective use of CSF diversion, for patients with intraoperative CSF leaks involving endoscopic endonasal approaches (EEA) to the skull base. Method: Consecutive endoscopic endonasal surgeries of the skull base from a pre-RCT cohort and post-RCT cohort were compared. The following case characteristics between the two cohorts were examined: patient age, body mass index (BMI), rate of revision surgery, tumor histology, use of CSF diversion, and vascularized reconstruction. The primary measured outcome was post-operative CSF leak. Results: The pre-RCT cohort included 76 patients and the post-RCT cohort, 77 patients, with dural defects in either the anterior or posterior cranial fossa (pituitary and parasellar/suprasellar surgeries excluded). There was a significant reduction in the incidence of post-operative CSF leak in the post-RCT cohort (27.6% vs. 12.9%; p=0.04). On subgroup analysis, there was a trend toward improvement in CSF leak rate of the anterior cranial fossa (19.2% vs 10.5%; p=0.27) whereas CSF leak rates of the posterior cranial fossa were significantly reduced compared to the pre-RCT cohort (41.4% vs 12.8%; p=0.02). Conclusion This study demonstrates that the integration of selective CSF diversion into the reconstructive algorithm improved post-operative CSF leak rates.

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

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.

scholarly journals Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control

2004 ◽  
Vol 62 (3b) ◽  
pp. 827-831 ◽  
Author(s):  
José Alberto Landeiro ◽  
Marlo S. Flores ◽  
Bruno C.R. Lázaro ◽  
Maria Helena Melo
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Management ◽  
Inferior Turbinate ◽  
Saline Injection ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Endoscopic Control ◽  
Free Grafts ◽  
Cranial Approach ◽  
Csf Leaks

The surgical management of cerebrospinal fluid (CSF) rhinorrhea has changed after the introduction of functional endoscopic sinus surgery.The following three cases illustrate the repair of CSF leaks with the use of rigid endoscope. Two patients had the diagnosis and the site confirmed after intrathecal fluoresceine saline injection. The obliteration of the CSF was achieved with fat free, mucoperichondrial or mucoperiostal free grafts taken from middle or inferior turbinate and kept in place by fibrin glue. Primary closure was achieved in all patients. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, effective and is a valid alternative to the cranial approach.

Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures

2012 ◽  
Vol 32 (6) ◽  
pp. E3 ◽  
Author(s):  
Mateo Ziu ◽  
Jennifer Gentry Savage ◽  
David F. Jimenez
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Head Injuries ◽  
Anterior Skull Base ◽  
Surgical Approaches ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Diagnosis And Management ◽  
Increased Risk ◽  
Technical Advances

Cerebrospinal fluid rhinorrhea is a serious and potentially fatal condition because of an increased risk of meningitis and brain abscess. Approximately 80% of all cases occur in patients with head injuries and craniofacial fractures. Despite technical advances in the diagnosis and management of CSF rhinorrhea caused by craniofacial injury through the introduction of MRI and endoscopic extracranial surgical approaches, difficulties remain. The authors review here the pathophysiology, diagnosis, and management of CSF rhinorrhea relevant exclusively to traumatic anterior skull base injuries and attempt to identify areas in which further work is needed.

Lymphangioma of the skull base bones leading to cerebrospinal fluid rhinorrhea

2008 ◽  
Vol 2 (4) ◽  
pp. 273-276 ◽  
Author(s):  
Eiji Ito ◽  
Kiyoshi Saito ◽  
Tetsuya Nagatani ◽  
Masaaki Teranishi ◽  
Yuzuru Kamei ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Differential Diagnosis ◽  
Skull Base ◽  
Histopathological Examination ◽  
Bone Destruction ◽  
Lytic Lesion ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage ◽  
The Right

Lymphangioma localized to the bones of the skull base is rare. The authors report herein the case of a 5-year-old boy who presented with lymphangioma of the bone, localized to the skull base and leading to cerebrospinal fluid (CSF) rhinorrhea with meningitis. Neuroimaging demonstrated lytic destruction with a cyst in the right middle skull base. The patient was successfully treated with resection of the tumor and prevention of CSF leakage. Histopathological examination revealed a lymphangioma. An enlarging lymphangioma can lead to bone destruction. A differential diagnosis of a lytic lesion for a cyst at the skull base is important for proper case management.

scholarly journals Endoscopic endonasal cerebrospinal fluid rhinorrhea repair: a cohort study in Iraq

2021 ◽  
Vol 37 (1) ◽  
Author(s):  
Ammar Abdulkadhim Hasan ◽  
Saad Farhan Al-Saedi ◽  
Mukhallad Mahdi Saleh ◽  
Hani Musa Al-Akbi
Keyword(s):  
Cerebrospinal Fluid ◽  
Success Rate ◽  
Fascia Lata ◽  
Csf Leak ◽  
Surgical Approaches ◽  
Tensor Fascia Lata ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Wide Range

Abstract Background Cerebrospinal fluid (CSF) rhinorrhea is a condition where the protective fluid that surrounds the brain finds its way into the nose and sinuses, often appearing as a very watery runny nose. The main surgical approaches for the surgical repair of CSF leaks are intracranial and extracranial. Over the last decade, endoscopic surgery has established itself as the most widely used technique for the repair of CSF fistula. The current study aimed to describe the use of nasal endoscopic technique in the management of cerebrospinal fluid rhinorrhea repair. Results Results of our study showed that in addition to CSF leak, 40% of the patients had headache and 17.5% had repeated meningitis. Half of the etiologies for the CSF leak were spontaneous, 35% were congenital, and 15% were traumatic. The more frequent site of leak was left cribriform plate (37.5%). In the majority of patients, 37/40 (92.5%), the type of graft was tensor fascia lata and fat, while in the remaining 3 patients, type of graft was tensor fascia lata and bone, bone and fat, and tensor fascia lata. The repair succeeded in 35 patients giving a success rate of 87.5%. Conclusion It can be concluded that wide range of age groups from 2–62 years presented as CSF rhinorrhea with female predominance, and there was high success rate of endoscopic CSF rhinorrhea repair with low morbidity.

scholarly journals Delayed Presentation of Traumatic Cerebrospinal Fluid Rhinorrhea: Case Report and Literature Review

2015 ◽  
Vol 6 (3) ◽  
pp. ar.2015.6.0132 ◽  
Author(s):  
Richard A. Guyer ◽  
Justin H. Turner
Keyword(s):  
Cerebrospinal Fluid ◽  
Head Injury ◽  
Skull Base ◽  
Late Onset ◽  
Closed Head Injury ◽  
Csf Leak ◽  
Delayed Presentation ◽  
Traumatic Head Injury ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea

Cerebrospinal fluid (CSF) leak is one of several complications that can occur after traumatic skull base injury. Although most patients present soon after the injury occurs, some can present years later, with resulting morbidity and the need for additional procedures. We present a case of a patient with a sphenoid sinus CSF leak who presented 12 years after a closed head injury that included a sphenoethmoid skull base fracture. We also reviewed the literature on this topic, with a discussion of previous reports of CSF leaks that occurred months, years, or decades after trauma. A late onset CSF leak appears to be a rare but important complication of traumatic skull base injury. This case highlights the need for clinicians to remain vigilant to the possibility of delayed CSF rhinorrhea, even years after traumatic head injury.

Traumatic Anterior Cranial Fossa CSF Leaks

Neurotrauma ◽  
2019 ◽  
pp. 93-102
Author(s):  
Omaditya Khanna ◽  
Tomas Garzon-Muvdi ◽  
Hermes Garcia ◽  
Richard F. Schmidt ◽  
James J. Evans ◽  
...  
Keyword(s):  
Skull Base ◽  
Anterior Cranial Fossa ◽  
Confirmatory Test ◽  
Ct Cisternography ◽  
Csf Rhinorrhea ◽  
Csf Leakage ◽  
Cranial Fossa ◽  
Csf Diversion ◽  
Magnetic Resonance Cisternography ◽  
Csf Leaks

Traumatic CSF leaks are reported to complicate 10–30% of skull base fractures. CSF rhinorrhea or otorrhea may be clinically apparent but in patients with less obvious leaks, β‎2-transferrin evaluation is the most sensitive and specific confirmatory test to establish the diagnosis of CSF leakage. High-resolution CT effectively identifies the majority of skull base fractures and sites of CSF leakage. Adjunctive imaging modalities such as CT cisternography and magnetic resonance cisternography may be used for further evaluation. Most traumatic CSF leaks of the anterior cranial fossa resolve spontaneously with conservative management including bedrest, head elevation, and avoidance of activities that increase intracranial pressure. The risk of meningitis increases significantly with persistent CSF leakage beyond 1 week, and intervention in the form of CSF diversion or surgical closure of the leak should be pursued. Prophylactic antibiotics have not been shown to decrease the risk of meningitis in patients with traumatic CSF leaks.

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