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ORIGINA L ARTICLE
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Skull Base, volume 13, number 2, 2003. Address for correspondence and reprint requests: M azhar H usain, M .Ch., Department ofNeurosurgery, King Georges M edical College, Lucknow 226003, India. E-mail: [email protected]. Departments of1Neurosurgery and 2Pathology, King Georges M edical College; 3Department of Radiology, Sanjay Gandhi Post- Graduate Insti tute ofM edical Sciences, Luchnow, India. Copyright 2003 by Thieme M edical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,USA. Tel: +1(212) 584-4662. 1531-5010,p;2003,13,02,073,078,ftx,en;sbs00323x.
Neuroendoscopic Transnasal Repair of
Cerebrospinal Fluid RhinorrheaM azhar Husain, M .Ch.,1 Deepak Jha, M.S.,1 Devendra K. Vatsal, M.Ch.,1
Nuzhat Husain, M .D.,2 and Rakesh K. Gupta, M .D.3
ABSTRACT
Cerebrospinal fluid (CSF) rhinorrhea is a common condition managedby most otolaryngologists with the help of nasal endoscopy (sinoscopy). In the
last 2 years, we have used a neuroendoscope with a working sheath to treat nine
patients with CSF rhinorrhea. One patient developed a recurrence 1 month after
treatment but then responded to conservative treatment. We conclude that the
treatment of CSF rhinorrhea by a neuroendoscope with a working sheath is safe,
effective, and easy and obviates the need for a separate sinoscope.
KEYWORDS: Cerebrospinal fluid, rhinorrhea, endoscopic surgery
first time to treat CSF rhinorrhea,10 the techniquehas gained increasing attention. The advantages of
endoscopic treatment such as excellent visualiza-
tion, precise graft placement, and shortened oper-
ating time have popularized it worldwide.1113 We
present our initial experience using a neuroendo-
scope with a working sheath to treat nine patients
with CSF rhinorrhea.
CLINICAL M ATERIALS AN D M ETHODS
Between M arch 1998 and November 2001, nine pa-
tients (five females and four males; mean age, 21.6
years; range, 2.5 to 36 years) were referred to our
Cerebrospinal fluid (CSF) rhinorrhea hasbeen a major treatment challenge for otolaryngol-ogists and skul l-base surgeons.1 Traumatic skull-
base fractures and iatrogenic injuries are the main
causes of CSF rhinorrhea,1 but the latter are rare
compared with the former.2 These fistulas must be
repaired to avoid imminent life-threatening com-
plicationslike ascending meningitis and pneumo-
cephalus.1
During the last 25 years, treatment of CSF
rhinorrhea has evolved from intracranial ap-
proaches35 to extracranial approaches.68 Extracra-nial approaches are equally successful and associated
with significantly fewer complications rates when
compared to intracranial approaches.9 Since 1981
when Wigand used endoscopic treatment for the
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74 SKULL BASE:AN INTERDISCIPLINARY APPROACH/VOLUME 13,NUMBER 2 2003
department with a possible clinical diagnosis of
CSF rhinorrhea. Three patients had spontaneous
and six had post-traumatic rhinorrhea.The durationof symptoms ranged from 5 months (in the case of
post-traumatic rhinorrhea) to 8 years (in the case of
spontaneous rhinorrhea). Three patients had a his-
tory of meningitis at some stage of the disorder. All
patients had failed conservative treatment.
All patients underwent a thorough clinical
examination, and the glucose concentration of the
nasal discharge (CSF) was analyzed. Six patients
underwent computed tomography (CT), seven un-
derwent magnetic resonance imaging (M RI), and
one underwent CT-cisternography. Four patientsunderwent both CT and MRI. One patient under-
went both M RI and CT-cisternography. Only MRI
localized sites of leakage.T2-weighted MRI showed
an arachnoid pouch prolapsing through the basal
defect in two patients and hyperintense CSF leak-
age into the sinus in four patients or into the nasal
cavity in one (Fig. 1). CT and CT-cisternography
showed fractured sites in patients with post-traumatic rhinorrhea but were inconclusive regard-
ing the exact location of the site of CSF leakage. In
two patients with post- traumatic rhinorrhea, the
leakage sites were primarily defined by endoscopy.
The leakage sites were at the anterior ethmoid in
five patients, the posterior ethmoid in three, and
the frontoethmoid in one.
Operative Technique
Patients were administered systemic antibiotics.
General anesthesia was induced with endotracheal
intubation. The head was slightly extended and
turned toward the right side (the side of the oper-
ating surgeon). The face and nasal cavity were
cleaned with soap and Betadine solution. A Gaab
universal endoscope (Karl-Storz,Tutt lingen, Ger-
many) was used (working sheath outer diameter,
6.5 mm;0-degree telescope, 2.7 mm;working chan-
nels, 1 and 2.7 mm). A TV monitor and camerawere attached to the endoscope for visual control
and teaching purposes.
Before the working sheath was introduced
into the nasal passage, adrenaline in saline (1:
100,000)-soaked cottonoids were left inside 3 to 5
minutes for hemostasis. The working sheath and
telescope were introduced under direct visualization
and were fixed with the Endoscope Holder (Aes-
culap,Tuttlingen, Germany). Injury to the mucosa
was avoided.
The fistula was localized by diagnostic en-doscopy.Leakage sites were identified as a pulsating,
glistening white arachnoid pouch in three patients
(Fig. 2A) or as CSF leaking through a dural rent in
six patients, confirming the findings on MRI. A
Valsalva maneuver was performed to confirm the
leak through the defect in cases of uncertainty.Fluo-
rescein dye was not used to localize the fistula.
The position of the working sheath changed
slightly, as needed, depending on the leakage site.
Figure 1 D emonstration of CSF rhinorrhea. T2-weighted
coronal M R I through the anterior ethmoid shows the
comm unication between the subarachnoid space and the
nasal cavity on the right side.
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NEUROENDOSCOPIC TRANSNASAL REPAIR OF CSF RHINORRHEA/HUSAIN ET AL 75
A
B C
Figure 2 Endoscopic view. (A ) Bulging arachnoid pouch through the defect in the anterior ethmoidal region. (B ) Leak-
ing CSF through the defect after the margin of the defect is defined and made raw by removing granulation tissue. (C)
D efect plugged by a fascia lata graft.
The superior turbinate was part ially resected to im-
prove visualization and intraoperative maneuver-
abil ity. The margin of the defect was defined andmade raw by removing any granulation tissue or
bone chips (Fig. 2B). Hemostasis was achieved by
applying unipolar coagulation. Intermit tent saline
irrigation through a fine catheter in the working
channel was used to clear the surgical field and tele-
scope lens. An appropriately sized fascia lata graft
(slightly larger than the defect) was created.
After the telescope and other instruments were
removed from the working sheath, the graft was in-
serted. The telescope was reintroduced to guide the
graft to the tip of the working sheath. Held by for-
ceps, the graft was insinuated into the defect a fewmillimeters, to plug it . The holding forceps were
withdrawn gradually by slightly rotating them, and
the graft was left in place (Fig. 2C). This was sup-
ported by Gelfoam sponge.The working sheath was
removed followed by the posterior nasal packing.
Post-operatively patients were confined to
bed rest with their heads elevated 30 degrees. In-
termi ttent lumbar drainage of CSF was done twice
a day for 3 to 5 days. Nasal packing was removed
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76 SKULL BASE:AN INTERDISCIPLINARY APPROACH/VOLUME 13,NUMBER 2 2003
48 to 72 hours after surgery. Patients were advised
to avoid straining and nose blowing during the im-
mediate postoperative period.
RESULTS
The rhinorrhea resolved completely in eight pa-
tients. One case of post-traumatic rhinorrhea re-
curred a month later but responded to conservative
treatment. There were no procedure-related com-
plications. Transient anosmia occurred in two pa-
tients but recovered spontaneously within a month.
DISCUSSION
Most neurosurgeons prefer the intracranial ap-
proach.14 Sphenoid sinus fistulas are approached
with great difficulty and may be inaccessible through
intracranial approaches because of adjacent neural
and vascular structures.15 Exposure of the skull base
and the necessity of brain retraction during intracra-nial procedures are associated with a significant risk
of anosmia, postoperative intracerebral hemorrhage,
and brain edema.16 The failure rate associated with
the management of CSF leaks via an intracranial ap-
proach has ranged from 20 to 40%.7,17,18
In contrast, extracranial approaches have
lower morbidity rates, higher success rates, and sel-
dom result in anosmia.6,7,11,12,16 They provide the best
exposure of the sphenoid, parasellar, and posterior
ethmoidal regions and offer excellent visualization of
fistulas in the posterior wall of the frontal sinus, thecribriform plate, and the fovea ethmoidalis.6,16,1921
Transnasal endoscopic surgery minimizes intranasal
trauma and preserves the bony framework support-
ing the frontal recess and other critical areas.22
M ostly otolaryngologists use a 4-mm sino-
scope to perform transnasal endoscopic treatment
of CSF rhinorrhea. The sinoscope, which is not
fixed, is usually held in one hand while the other
hand guides the instrument. This configuration
risks injury to the passage. A system with a work-ing sheath, which is fixed with an Endoscope
Holder, eliminates unwanted movement and frees
both hands for surgical maneuvering.Working chan-
nels in the sheath allow other instrumentation to
be inserted without causing injury. The field and
lens can also be irrigated when obscured by bleed-
ing or cauterization. Once inserted, the working
sheath remains until the procedure is completed. In
contrast, a sinoscope must be withdrawn multiple
times for cleaning and surgical maneuvers.
Various dyes like methylene blue, phenolsul-fonphthalein, indigo carmine, and fluorescein have
been used to demonstrate the osculum of the fis-
tula.23,24 Fluorescein is still in use but is not pre-
ferred because it is associated with complications
like transverse myelitis and allergic reactions.25The
Valsalva maneuver has been used to detect ambigu-
ous sites of leakage in CSF rhinorrhea. We have also
used the Valsalva maneuver, which clearly helped
demonstrate the location of the CSF leak.
A pedicled flap-like septal mucoperiosteum
or a free graft from temporalis fascia, fascia lata,free muscle, tragal perichondrium, abdominal fat,
or even an omental free flap of synthetic dural sub-
stitute can be used for the endoscopic repair of CSF
fistulas.1,16,2628 Free grafts are less bulky and are
thought to interfere less with postoperative nasal
function.9 Theoretically, tenting or folding the pedi-
cled flap could cause the defect to seal inadequately.12
Fibrin glue has been used to secure the graft
into position in previous studies.28,29 In our series,
plugging the graft into the defect required no fur-
ther reinforcement by fibrin glue, thereby reducingthe cost of t reatment. We used autologous fascia
lata graft, which can easily be obtained from thigh
through a very small incision, in all our cases.
We conclude that endoscopic treatment of
CSF rhinorrhea with a neuroendoscope with a work-
ing sheath is relatively inexpensive, effective, safe,
and less traumatic.
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NEUROENDOSCOPIC TRANSNASAL REPAIR OF CSF RHINORRHEA/HUSAIN ET AL 77
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19. Briant TDR, Snell E. Diagnosis of cerebrospinal rhinor-rhoea and the rhinologic approach to i ts repair. Laryngo-scope 1976;77:13901409
20. M cCabe BF. The osteo-mucoperiosteal flap in repair ofcerebrospinal fluid rhinorrhoea. Laryngoscope 1976;86:537539
21. M ontgomery WW. Surgery of cerebrospinal fluid rhinor-rhoea and otorrhoea. Arch Otolaryngol 1966;84:92104
22. Schaefer SD, M anning S, Close LG. Endoscopic paranasalsinus surgery: indications and considerations. Laryngo-scope 1989;99:15
23. Strauss H . Fluorescein als indikator fuer die Nierenfunk-ti on. Kl in Wochenschr 1913;50:22262227
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pair of cerebrospinal fluid rhinorrhoea. Br J Neurosurg2000;14:4952
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Commentary
This article reviewed the endoscopic man-agement of cerebrospinal fluid (CSF) leaks,a tech-
nique that has been used since the 1980s. The au-
thors treated nine cases over 3 years and had good
results in eight of the nine cases after the original
operation.
This technique is well known to otolaryn-
gologists. At many hospitals, it is the fi rst- line treat-ment offered for a CSF leak from the skull base
judged to be reachable with an endoscope. I t is rea-
sonable to use the technique, rather than intracra-
nial or transcranial approaches (which can be held
as back-ups for endoscopic failure), to deal with the
problem. The technique is advantageous because of
its ease of access. In fact, it is an extracranial proce-
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78 SKULL BASE:AN INTERDISCIPLINARY APPROACH/VOLUME 13,NUMBER 2 2003
dure and is performed on an outpatient basis with
local anesthesia and intravenous sedation. In expe-
rienced hands, the morbidity rate is minimal.
Ian T. Jackson, M .D.1
Commentary
The authors report nine patients who under-went endoscopic repair of a cerebrospinal fluid (CSF)
leak.They achieved excellent results using a much less
invasive approach than a traditional bifrontal cran-
iotomy.We prefer to use septal or conchal cartilage to
fi ll the defect. We also use temporalis fascia.We have
not used fluorescein dye and have been able to visual-
ize CSF leakage without difficulty. Furthermore, theuse of flourescein intrathecally has been associated
with seizures. We also supplement the repair with
Gelfoam and fibrin glue to seal the defect. Finally, we
use frameless image guidance during surgery to avoid
perforation through the anterior cranial fossa and to
achieve the most direct approach. Clearly, this
approach has become a very attractive, less invasive
option for the treatment of CSF leaks. In most cases,
it should be attempted before a craniotomy.
Randall W. Porter,M .D.1
Skull Base, volume 13,number 2,2003. 1Insti tute for Craniofacial and Reconstructive Surgery,Southfield, M ichigan.Copyright 2003 byThieme M edical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 1531-5010,p;2003,13,02,077,078,ftx,en;sbs00324x.
Skull Base, volume 13, number 2, 2003. 1Interdisciplinary Skull Base Section, Division of Neurological Surgery, Barrow NeurologicalInsti tute, Phoenix, Arizona.Copyright 2003 by Thieme M edical Publishers, Inc.,333 Seventh Avenue, New York, NY 10001,USA. Tel:+1(212) 584-4662. 1531-5010,p;2003,13,02,078,078,ftx,en;sbs00325x.