Endonasal endoscopic repair of anterior skull-base fistulas: the Kuala Lumpur experience

Abstract

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.

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

“…72,80 Various authors have successfully used different types of autologous and nonautologous grafts, such as a mucoperiosteal flap from the middle turbinate or septum or mucoperichondrial, osseous, cartilaginous, fat, muscular fascia, middle turbinate, or septum pedunculated graft, or any combination of these grafts. 1,3,11,13,15,22,[24][25][26]28,35,47,51,55,56,64,65,67,77,79,90,101,108 Another widely discussed issue in endoscopic transnasal repair is whether the grafts used for repair should be placed above (inlay) or beneath (onlay) the skull base defects. In a meta-analysis, Hegazy et al 53 found that both techniques yielded similar results.…”

Extended applications of endoscopic sinus surgery and its reference to cranial base and pituitary fossa

“…In experienced hands, it is possible to obtain better access to the orbital apex and even to decompress the optic nerve endoscopically [18]. Hypertrophy of the extraocular muscles and orbital fat in thyroid eye disease is one of the commonest causes of proptosis.…”

Spontaneous pseudomeningocele of sphenoid sinus or sphenoid mucocele?: A diagnosis dilemma

“…Many operative techniques and different types of graft material have been described (10). The grafts described include a nasal mucosal flap, free graft of nasal mucosa which may be a composite graft incorporating turbinate bone, conchal or septal cartilage, temporalis fascia and fascia lata which may be supported by fat (11)(12)(13). All of these techniques give a good success rate.…”