Subscribe to RSS
DOI: 10.1055/s-2001-12787
Endonasal Endoscopic Closure of Cerebrospinal Fluid Rhinorrhea
Publication History
Publication Date:
31 December 2001 (online)
![](https://www.thieme-connect.de/media/sbs/200101/lookinside/thumbnails/10.1055-s-2001-12787-1.jpg)
ABSTRACT
The authors review their experience with endoscopic repair of skull base defects associated with cerebrospinal fluid (CSF) rhinorrhea involving the paranasal sinuses. A total of 22 patients was treated endoscopically between 1992 and 1998. The repair method consisted of closure of the CSF fistula with a free autologous abdominal fat graft and fibrin glue, supported with a sheet of silastic. The primary closure rate was 82% (18/22), and the overall closure rate was 95.5% (21/22) without recurrence or complications within an average follow-up of 5 years (14-83 months). A single patient still complains of cerebrospinal rhinorrhea, although this was never proved by any clinical, endoscopic, or biological (β2-transferrin) examination. The repair of ethmoidal-sphenoidal cerebrospinal fluid fistulae by endonasal endoscopic surgery is an excellent technique, both safe and effective. Fat is a material of choice, as it is tight and resists infection well. The technique and indications for endoscopic management of cerebrospinal fluid leaks are discussed.
KEYWORD
Cerebrospinal fluid rhinorrhea - fat graft - endoscopic treatment - anterior cranial fossa - ethmoid - sphenoidal sinus - MRI cisternography
REFERENCES
- 1 Wigand M E. Transnasal ethmoidectomy under endoscopic control. Rhinology . 1981; 19 7-15
- 2 Stankiewicz J A. Complications in endoscopic intranasal ethmoidectomy: an update. Laryngoscope . 1989; 99 686-690
- 3 Mattox D E, Kennedy D W. Endoscopic management of cerebrospinal fluid leaks and cephaloceles. Laryngoscope . 1990; 100 857-862
- 4 Papay F A, Maggiano H, Dominquez S. Rigid endoscopic repair of paranasal sinus cerebrospinal fluid fistulas. Laryngoscope . 1989; 99 1195-1201
- 5 Stankiewicz J A. Cerebrospinal fluid fistula and endoscopic sinus surgery. Laryngoscope . 1991; 101 250-256
- 6 Levine H L. Endoscopic diagnosis and management of cerebrospinal fluid rhinorrhea. Operative technique. Otolaryngol Head Neck Surg . 1991; 2 282-284
- 7 Dodson E, Gross C W, Swerdloff J L, Gustafson M. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. Otolaryngol Head Neck Surg . 1994; 111 600-605
- 8 Ommaya A K. Cerebrospinal fluid rhinorrhea. Neurology . 1964; 15 106-113
- 9 Charles D A, Snell D. Cerebrospinal fluid rhinorrhea. Laryngoscope . 1979; 89 822-826
- 10 Blennow K, Fredman P. Detection of cerebrospinal fluid leakage by isoelectric focusing on polyacrylamide gels with silver staining using the PhastsystemTM . Acta Neurochir . 1995; 136 135-139
- 11 Ohnishi T. Bony defects and dehiscences of the roof of the ethmoid cells. Rhinology . 1981; 19 195-202
- 12 Kosoy J, Trieff N M, Winkelmann P. Glucose in nasal secretions. Arch Otolaryngol . 1972; 95 225-229
- 13 Irjala K, Suonpää J, Laurent B. Identification of CSF leakage by immunofixation. Arch Otolaryngol . 1979; 105 447-448
- 14 Oberascher G. A modern concept of cerebrospinal fluid diagnosis in oto- and rhinorrhea. Rhinology . 1988; 26 89-103
- 15 Middelweerd M J, De Vries N, Calliauw J, Van Kamp J G. A new biochemical assay in the diagnostic management of nasal cerebrospinal fluid leakage. Eur Arch Otolaryngol . 1995; 252 336-339
- 16 Brunon J, Duthel R, Motuo-Fotso M J, Huppert J. Rhinorrhée spontanée révélatrice d'une méningoencéphalocèle intranasale et d'un épendymome du IVème ventricule. Neurochirurgie . 1990; 36 383-387
- 17 Burns J A, Dodson E E, Gross C W. Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up. Laryngoscope . 1996; 106 1080-1083
- 18 Calcaterra T C. Extracranial surgical repair of cerebrospinal rhinorrhea. Ann Otol . 1980; 89 108-116
- 19 Skedros D G, Cass S P, Hirsch B E. Sources of error in use of Beta-2 transferrin analysis for diagnosing perilymphatic and cerebral spinal fluid leaks. Otolaryngol Head Neck Surg . 1993; 109 861-864
- 20 Kirchner F R, Proud G O. Method for the identification and localisation of cerebrospinal fluid Rhinorrhea and otorrhea. Laryngoscope . 1960; 70 921-931
- 21 Messerklinger W. Nasenendoskopie: Nachweis, Lokalisation und differentialdiagnose der nasalen Liquorrhoe. Head Neck Otolaryngol . 1972; 20 268-270
- 22 Brown E M, De Louvois J, Bayston R. Antimicrobial prophylaxis in neurosurgery and after head injury. Lancet . 1994; 344 1547-1551
- 23 Crow H J, Keogh C, Northfield D WC. The localisation of cerebrospinal fluid fistulae. Lancet . 1956; 271 325-327
- 24 Drayer B P, Wilkins R H, Boehnke E M. Cerebrospinal fluid rhinorrhea demonstrated by metrizamide CT cisternography. AJR . 1977; 129 149-151
- 25 Curnes J T, Vincent L M, Kowaslsky R J. CSF rhinorrhea: detection and localization using overpressure cisternography with Tc-99m-DTPA. Radiology . 1985; 154 795-799
- 26 De Tovar G, Akerman M, Jedynak C P, Derome P. La cisternographie isotopique hyperbare pour la recherche des fuites de liquide céphalo-rachidien. Nouv Presse Med . 1976; 5 1433
- 27 Colquhoun I R. CT cisternography in the investigation of cerebrospinal fluid rhinorrhea. Clin Radiol . 1993; 47 403-408
- 28 Eljamel M S, Pidgeon C N, Toland J. MRI cisternography and the localization of CSF fistulae. Br J Neurosurg . 1994; 8 433-437
- 29 Lloyd M NH, Kimber P M, Burrows E H. Post-traumatic cerebrospinal fluid rhinorrhea: modern high-definition computed tomography is all that is required for the effective demonstration of the site of leakage. Clin Radiol . 1994; 49 100-103
- 30 Eljamel M S, Pidgeon C N. Localization of inactive cerebrospinal fluid fistulas. J Neurosurg . 1995; 83 795-798
- 31 Gacek R R, Gacek M R, Tart R. Adult spontaneous cerebrospinal fluid otorrhea: diagnosis and management. Am J Otol . 1999; 20 770-776
- 32 Levy L M, Gulya A J, Davis S W. Flow-sensitive magnetic resonance imaging in the evaluation of cerebrospinal fluid leaks. Am J Otol . 1995; 16 591-596
- 33 Stafford Johnson B D, Brennan P, Toland J, O'Dwyer A J. Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistulae. Clin Radiol . 1996; 51 837-841
- 34 Wakhloo A K, Van Velthoven V, Schumacher M, Krauss J K. Evaluation of MR imaging, digital substraction cisternography and CT cisternography in diagnosing CSF fistula. Acta Neurochir . 1991; 111 119-127
- 35 Gates G A, Sertl G O, Grubb R L, Wippold F J. Closure of clival cerebrospinal fluid fistula with biocompatible osteoconductive polymer. Arch Otolaryngol Head Neck Surg . 1994; 120 459-461
- 36 Shetty P G, Shroff M M, Sahani D V, Kirtane M V. Evaluation of high-resolution CT and MR Cisternography in the diagnosis of cerebrospinal fistula. AJNR Am J Neuroradiol . 1998; 19 633-639
- 37 El Gammal T, Sobol W, Van Wadlington R. Cerebrospinal fluid fistula: detection with MR cisternography. AJNR Am J Neuroradiol . 1998; 19 627-631
- 38 Gupta V, Goyal M, Mishra N. MR evaluation of CSF fistulae. Acta Radiol . 1997; 38 603-609
- 39 George B, Jamet P, Frerebeau P. Materials for osteo-dural reconstruction in the cranium: an update [article in French]. J Neurochir . 1989; 35 145-151
- 40 Montgomery W W. Surgery for cerebrospinal fluid rhinorrhea and otorrhea. Arch Otolaryngol . 1966; 84 92-104
- 41 Junien-Lavillauroy C, Chirossel J P, Reyt E. La reconstruction dans les voies mixtes pour chirurgie des tumeurs de l'ethmoïde. J Fr Oto-Rhino-Laryngol . 1991; 40 154-158
- 42 Lanza D C, O'Brien D A, Kennedy D W. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope . 1996; 106 1119-1125
- 43 Saccogna P W, Werning J W, Setrakian S, Strauss M. Lipoinjection in the paralyzed feline vocal fold: study of graft survival. Otolaryngol Head Neck Surg . 1997; 117 465-470
- 44 Wethmore S J. Injection of fat for soft tissue augmentation. Laryngoscope . 1989; 99 50-57
- 45 Peer L A. Transplantation of fat. In: Peer LA, ed. Transplantation of Tissue Baltimore, MD: Williams & Wilkins 1969: 165-244
- 46 Nguyen A, Pasyk K A, Bouvier T N. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg . 1990; 85 378-386
- 47 Nicklaus P, Dutcher P O, Kido D K. New imaging techniques in diagnosis of cerebrospinal fluid fistula. Laryngoscope . 1988; 8 1065-1068
- 48 Findler G, Sahar A, Beller A. Continuous lumbar drainage of cerebrospinal fluid in neurosurgical patients. Surg Neurol . 1977; 8 455-457
- 49 Shapiro S A, Scully T. Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula. Neurosurgery . 1992; 30 241-245
- 50 Castillo L, Paquis P, Melanger M. Rhinorrhée cérébro-spinale: traitement par voie endonasale sous guidage endoscopique. J Fr Oto-Rhino-Laryngol . 1996; 45 395-399
- 51 Wigand M E, Hosemann W G. Results of endoscopic surgery of the paranasal sinuses and anterior skull base. J Otolaryngol . 1991; 20 385-390
- 52 Stankiewicz J A. The endoscopic approach to the sphenoid sinus. Laryngoscope . 1989; 99 218-221
- 53 Wax M K, Ramadan H H, Ortiz O, Wethmore S J. Contemporary management of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg . 1997; 116 442-449
- 54 Hughes R GM, Jonest N S, Robertson I JA. The endoscopic treatment of cerebrospinal fluid rhinorrhoea: the Nottingham experience. J Laryngol Otol . 1997; 111 125-128
- 55 Gjuric M, Goede U, Keimer R H, Wigand M E. Endonasal endoscopic closure of cerebrospinal fluid fistulas at the anterior cranial base. Ann Otol Rhinol Laryngol . 1996; 105 620-623
- 56 Schmerber S, Chen B, Lavallée S. La chirurgie endonasale sous guidage endoscopique assistée par ordinateur. Ann Otolaryngol Chir Cervicofac 117:in press.