Endoscopic Endonasal Approach for Cerebrospinal Fluid Fistulae

Abstract

Different techniques have been proposed to repair cerebrospinal fluid rhinorrhea. Advances in nasal surgery led to a high success rate and low morbidity for the endonasal approach. It has become the favorite route for treating cerebrospinal fluid leaks of the anterior skull base. Better results have been obtained with the improvement of rigid endoscopes and intrathecal sodium fluorescein. In a prospective study, twenty-four patients with cerebrospinal fluid rhinorrhea were evaluated and treated by endoscopic endonasal surgery. In all cases intrathecal sodium fluorescein enabled a precise localization of the bone defect. The most common causes of CSF rhinorrhea were traumatic (8 cases, 33 %), spontaneous (6 cases, 25 %), and iatrogenic (5 cases, 20.8 %). Preoperative radiological evaluations (plane CT, CT cisternogram and MRI) showed the exact site and size of the defect in all patients. The most common site of leakage was the ethmoidal roof-cribriform plate. Primary closure was achieved in all patients. There were no major operative or postoperative complications. The endoscopic endonasal approach can be considered the first choice in the treatment of cerebrospinal fluid rhinorrhea.

Key words

Cerebrospinal fluid - fistulae - endoscopic endonasal approach - paranasal sinus

References

• 1 Hegazy H M, Carrau R L, Snyderman C H, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.  Laryngoscope. 2000;  110 1166-1172
• 2 Dandy W. Pneumocephalus (intracranial pneumatocele or aerocele).  Arch Surg. 1926;  12 949-982
• 3 Dohlman G. Spontaneous cerebrospinal rhinorrhea.  Acta Otolaryngol. 1948;  67 (Suppl) 20-23
• 4 Hirsch O. Successful closure of cerebrospinal fluid rhinorrhea by endonasal surgery.  Arch Otolaryngol. 1952;  56 1-13
• 5 Stammberger H, Greistorfer K, Wolf G, Luxemberger W. Operativer Verschluß von Liquorfisteln der vorderen Schädelbasis unter intrathekaler Natrium-Fluoreszeinanwendung.  Laryngol Rhinol Otol. 1997;  76 595-607
• 6 Stamm A C, Freire L AS. Microendoscopic surgery of the paranasal sinuses and the skull base. In: Stamm AC, Draf W (eds). Microscopic and endoscopic surgery of the nose and sinuses. Heidelberg, New York, Berlin, Springer Verlag 2000: 451-463
• 7 Costa H, Cerejo A, Baptista A, Vaz R, Gonçalves M, Guimarães A. et al . The galea frontalis myofascial flap in anterior fossa CSF leaks.  Br J Plast Surg. 1993;  46 503-507
• 8 Park J I, Strelzow V V, Friedman W H. Current management of cerebrospinal fluid rhinorrhea.  Laryngoscope. 1983;  93 1294-1300
• 9 Guimarães R, Becker H. A new technique for the use of intrathecal fluorescein in the repair of CSF rhinorrhea using a hypodense diluent.  Rev Laryngol Otol Rhinol. 2001;  122 (3) 195-200
• 10 Jho H D, Alfieri A. Endoscopic endonasal pituitary surgery: evolution of surgical technique and equipment in 150 operations.  Minim Invas Neurosurg. 2001;  44 1-12
• 11 Cappabianca P, Alfieri A, de Divitiis E. Endoscopic endonasal transsphenoidal to the sella:towards functional endoscopic pituitary surgery.  Minim Invas Neurosurg. 1998;  41 66-73
• 12 Wigand W E. Transnasal ethmoidectomy under endoscopic control.  Rhinology. 1981;  19 7-15
• 13 Stankiewicz J A. Cerebrospinal fluid fistula and endoscopic sinus surgery.  Laryngoscope. 1991;  101 250-256
• 14 Lanza D C, O'Brien D A, Kennedy D W. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles.  Laryngoscope. 1996;  106 1119-1125
• 15 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
• 16 Mattox D E, Kennedy D W. Endoscopic management of cerebrospinal fluid leaks and cephaloceles.  Laryngoscope. 1990;  100 857-862
• 17 Applebaum E L, Chow J M. Otolaryngology head and neck surgery, volume 2-A, 3rd edn. In: Cummings CW, Fredrickson JM, Harker LA et al. (eds). London: Mosby 1999
• 18 Daly D T, Lydiatt W M, Ogren F P, Moore G F. Extracranial approaches to repair of cerebrospinal fluid rhinorrhea.  Ear Nose Throat J. 1992;  71 311-313
• 19 El-Banhawy O A, Halaka A N, El-Dien A ES, Ayad H. Subcranial transnasal repair of cerebrospinal fluid rhinorrhea with free autologous grafts by the combined overlay and underlay techniques.  Minim Invas Neurosurg. 2004;  47 197-202
• 20 Landeiro J A, Flores M S, Lázaro B CR, Melo M H. Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control.  Arq Neuropsiquiatr. 2004;  62 (3-B) 827-831
• 21 Kelley T F, Stankiewicz J A, Chow J M, Origitano T C, Shea J. Endoscopic closure of post surgical anterior cranial fossa cerebrospinal fluid leaks.  Neurosurgery. 1996;  39 743-746
• 22 Montgomery W W. Cerebrospinal rhinorrhea.  Otolaryngol Clin North Am. 1973;  6 757-771
• 23 Yessenow R S, McCabe B F. The osteomucoperiosteal flap in repair of CSF rhinorrhea: a 20-year experience.  Otolaryngol Head Neck Surg. 1989;  101 555-558
• 24 Papay F A, Maggiano H, Dominquez S, Hassenbusch S J, Levine H L, Lavertu P. Rigid endoscopic repair of paranasal sinus cerebrospinal fluid fistulas.  Laryngoscope. 1989;  99 1195-1201
• 25 Velthoven V van, Clarici G, Auer L M. Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery.  Acta Neurochir (Wien). 1991;  109 26-29