Endoscopic and fluoroscopic-guided closure of the eustachian tube using a biliary cytology brush and liquid embolic agent for a persistent CSF leak after schwannoma resection

Vestibular schwannoma is a known cause of progressive sensorineural hearing loss. Treatment options include observation, radiation therapy and surgical resection. Cerebrospinal fluid (CSF) fistula is a known postsurgical complication that can lead to CSF otorrhoea, rhinorrhoea or CSF leakage from the surgical wound. We present a case report of a patient who underwent vestibular schwannoma resection and postoperatively developed CSF rhinorrhoea, which was refractory to multiple attempts at surgical repair. This was successfully treated under endoscopic and fluoroscopic guidance using a biliary cytology brush to disrupt the surface of the eustachian tube followed by injection of n-Butyl cyanoacrylate.

Cerebrospinal Fluid Rhinorrhea as the First Symptom of Metastatic Prostate Adenocarcinoma

The most common cause of cerebrospinal fluid (CSF) rhinorrhoea is damage to the skull base with a dura mater’s rupture due to an accident or an iatrogenic injury. This applies to over 96% of cases. Other possibilities that can lead to CSF leakage are neoplasms of the nasal cavity, paranasal sinuses, and nasopharynx. Although prostate cancer spreads to bones, cranial metastases to paranasal sinuses are extremely rare. We present a case of an 83-year-old patient with CSF leakage due to infiltrating metastatic prostate cancer. Cerebrospinal fluid rhinorrhea turned out to be the first symptom of prostate cancer metastasis. Diagnostic and treatment strategies are presented in the discussion.

926 CSF Rhinorrhoea After Endonasal Intervention to The Skull Base (CRANIAL): Multicentre Pilot Study

Introduction CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective, multicentre observational study seeking to determine: the scope of skull base repair methods used, and the corresponding rates of postoperative CSF rhinorrhoea in endonasal transsphenoidal (TSA) expanded endonasal approaches (EEA) for skull base tumours. Method A prospective, observational cohort pilot study was carried out at eleven neurosurgical units, via NANSIG and BNTRC collaboratives. Results 192 cases were included – 167 TSA (87%), 25 EEA (13%). The most common (MC) pathologies included: pituitary adenomas (n = 150/192), craniopharyngiomas (n = 7/192) and meningiomas (n = 4/192). The MC skull base repair techniques used were tissue glues (n = 135/192, MC Tisseel®), grafts (n = 94/192, MC fat or Spongostan™) and vascularised flap (52/192, MC nasoseptal). These repairs were most frequently supported by nasal packs (n = 127/192) and lumbar drains (n = 23/197). Biochemically confirmed CSF rhinorrhoea occurred in 10/167 (6%) TSA and 4/25 (16%) EEA. 5 cases required operative management for CSF rhinorrhoea (CSF diversion or direct repair). Qualitative feedback was largely positive (e.g., user-friendly data collection), demonstrating acceptability. Conclusions Our pilot experience highlights the acceptability and feasibility of CRANIAL. There is clear precedent for multicentre dissemination of this project, in order to establish a benchmark of contemporary skull base neurosurgery practice.

A OBSERVATIONAL STUDY OF ENDOSCOPIC REPAIR OF CSF RHINORRHOEA

Background: Intrathecal fluorescein may be used to visualize CSF fistulas using a nasal endoscope. This allows the examiner to directly visualize the size of the defect, its location, and its rate of flow. The first repair of CSF leak was performed by Dandy in 1926 using a frontal craniotomy. This technique had a 60-80% success rate and was the gold standard for decades. In 1964Vrabec and Hallberg described the endonasal approach of CSF leak repair. AIMS: This study aims to establish the success rate of endoscopic surgical repair of CSF rhinorrhoca. MATERIALS AND METHODS: The study was conducted in Department of ENT IPGMER and SSKM Hospital. During the study period of 18 months, 30 patients have been admitted in our department with CSF leak (most of them were referred from neurosurgery). RESULTS: Fat and fascia lata and temporalis fascia were used to repair CSF leak in 24 patients. Bath plug technique was applied for 3 patients. Repair with vascularised flap such as Hadad flap or middle turbinate graft were used in case of 3 patients. CSF rhinorrhoea repair was successful in 28 out of 30(94%) patients after primary surgery whereas recurrence occurred in 2(6%) cases. Among them 1 patient underwent second surgery which achieved definitive closure of the leak. But one case lost follow up and did not come for second surgery. Interval between surgery and recurrence was varied and so were the causes. CONCLUSION: CSF rhinorrhoea cases can be repaired by an endoscopic approach with a high success rate. Radiological investigation of PNS and brain are equally important for selection of cases for endoscopic repair. Spontaneous leak must be checked cautiously to exclude features of raised ICT. Relapse occurs mainly for failure to delineate actual site or sites of leak and inadequate size or faulty placement of graft. Success depends not only on surgical skill but also on baseline intracranial tension, cause & site of leak and postoperative care.

Endoscopic endonasal repair of a cerebrospinal fluid leak secondary to a meningoencephalocele using a posterior – based middle turbinate flap

Cerebrospinal fluid leaks are rare but remain an important differential diagnosis for patients presenting with persistent, unilateral rhinorrhoea. This case describes a middle-aged female with persistent left sided rhinorrhea. She was minimally responsive to treatment for chronic sinusitis. On re-evaluation, a cerebrospinal fluid leak secondary to a meningoencephalocele was identified. This was subsequently repaired with a pedicled, vascularized graft using an endoscopic endonasal approach. The discussion which follows reviews the management of CSF rhinorrhoea with an emphasis on the available surgical options as well as the materials used for repair.