The Endonasal Endoscopic Management of Cerebrospinal Fluid Rhinorrhea

Abstract

Introduction Cerebrospinal fluid (CSF) rhinorrhea is the result of a bony defect at the skull base with disruption of the arachnoid, dura mater, and sinonasal mucosa that leads to an active CSF leak and flow of clear fluid from the nose. The endoscopic repair of CSF leaks and skull defects have been used by an increasing number of surgeons and is the standard of care for repairing CSF leaks. Materials and methods We conducted a retrospective study of all cases of CSF leaks managed via the endonasal endoscopic approach from 2010 to 2020 at a tertiary referral hospital of King Fahad Specialist Hospital, Dammam (KFSH-D). Results Over 10 years, 61 procedures were performed on a total of 56 patients (average age, 39.9 years) with 26 spontaneous CSF leaks and 30 traumatic CSF leaks. The leak sites were frontal bone in 14% of the cases, the roof of the ethmoid in 25%, the cribriform plate of ethmoid in 39%, and the walls of sphenoid sinus in 21%; multiple site defects were found in eight patients. The defect was localized by high-resolution computed tomography (CT) of the paranasal sinuses and skull base and magnetic resonance imaging (MRI) in all patients. CT cisternography, intrathecal fluorescein injection, and topical application of fluorescein dye were used in patients as required. A combination of free grafts and flaps materials were used in most patients. A middle and inferior turbinate graft was used in 12 patients, a septal cartilage graft in 18 patients, and a pedicled nasoseptal flap in 12 patients. The success rate was 92% after the first closure attempt. A recurrence of CSF leaks was observed in four patients. The mean hospitalization time was 6.5 days. The postoperative follow-up period ranged from one year to 10 years with a mean postoperative follow-up time of three years. Conclusions The endonasal endoscopic approach is the current standard of care for repairing most CSF leaks and skull base defects. We have had an excellent experience with endonasal endoscopic CSF leak repair, with high success rates and low morbidity. Our results support the effectiveness and safety of this technique and should encourage otolaryngologists to apply the procedure in cases of CSF leak.

Cirugía endoscópica transnasal de base de cráneo: Análisis de las complicaciones en los primeros 120 procedimientos

“…Por ejemplo, la reparación endoscópica de defectos de la base del cráneo, como las fístulas de LCR, se asocia a menor tasa de complicaciones que la resección endoscópica de tumores. [ 3 , 13 , 14 , 16 ] Con respecto a los tumores de la base del cráneo, las lesiones benignas a menudo requieren una resección quirúrgica menos agresiva y por lo tanto, es menos probable que provoquen complicaciones. [ 12 ] En nuestra cohorte registramos 26 complicaciones (21.66%) distribuidas en 24 pacientes y solo 2 fallecimientos durante la internación.…”

Management of Traumatic and Non-Traumatic Cerebrospinal Fluid Rhinorrhea—Experience from Three Southeast Asian Countries

“…These rates are superior compared to the success rates of 86% in craniotomy and extracranial methods for the surgical repair of CSF leaks [ 37 ]. A review of recent studies published over the past 5 years showed a high success rate with zero or very minimal immediate postoperative complications ( Table 6 ) [ 8 , 30 , 31 , 32 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. The variable success rates of endoscopic repair most likely reflect the surgeons’ technical experience, the timing of management, and the nature of the leak (high-pressure versus low-pressure).…”

Cerebrospinal fluid rhinorrhea: a novel approach

“…A history of a sinonasal or neurosurgical procedure, head trauma, meningitis, and intracranial or skull base tumors should raise the suspicion of CSF leak. 12…”