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ORIGINAL ARTICLE

Neuroendoscopic Transnasal Repair of Cerebrospinal Fluid Rhinorrhea


Mazhar 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 managed by 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

Cerebrospinal fluid (CSF) rhinorrhea has


been a major treatment challenge for otolaryngologists and skull-base surgeons.1 Traumatic skullbase 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 complications like ascending meningitis and pneumocephalus.1 During the last 25 years, treatment of CSF rhinorrhea has evolved from intracranial approaches35 to extracranial approaches.68 Extracranial 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

first time to treat CSF rhinorrhea,10 the technique has gained increasing attention. The advantages of endoscopic treatment such as excellent visualization, precise graft placement, and shortened operating time have popularized it worldwide.1113 We present our initial experience using a neuroendoscope with a working sheath to treat nine patients with CSF rhinorrhea.

CLINICAL MATERIALS AND METHODS Between March 1998 and November 2001, nine patients (five females and four males; mean age, 21.6 years; range, 2.5 to 36 years) were referred to our

Skull Base, volume 13, number 2, 2003. Address for correspondence and reprint requests: Mazhar Husain, M.Ch., Department of Neurosurgery, King Georges Medical College, Lucknow 226003, India. E-mail: mazharhusain@hotmail.com. Departments of 1Neurosurgery and 2Pathology, King Georges Medical College; 3Department of Radiology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Luchnow, India. Copyright 2003 by Thieme Medical 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.

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department with a possible clinical diagnosis of CSF rhinorrhea. Three patients had spontaneous and six had post-traumatic rhinorrhea. The duration of 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 history 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 underwent magnetic resonance imaging (MRI), and one underwent CT-cisternography. Four patients underwent both CT and MRI. One patient underwent both MRI 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 posttraumatic rhinorrhea but were inconclusive regarding 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 operating surgeon). The face and nasal cavity were cleaned with soap and Betadine solution. A Gaab universal endoscope (Karl-Storz, Tuttlingen, Germany) was used (working sheath outer diameter, 6.5 mm; 0-degree telescope, 2.7 mm; working channels, 1 and 2.7 mm). A TV monitor and camera were 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 (Aesculap, Tuttlingen, Germany). Injury to the mucosa was avoided. The fistula was localized by diagnostic endoscopy. 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. Fluorescein 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 Demonstration of CSF rhinorrhea. T2-weighted coronal MRI through the anterior ethmoid shows the communication between the subarachnoid space and the nasal cavity on the right side.

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Figure 2 Endoscopic view. (A) Bulging arachnoid pouch through the defect in the anterior ethmoidal region. (B) Leaking CSF through the defect after the margin of the defect is defined and made raw by removing granulation tissue. (C) Defect plugged by a fascia lata graft.

The superior turbinate was partially resected to improve visualization and intraoperative maneuverability. The margin of the defect was defined and made raw by removing any granulation tissue or bone chips (Fig. 2B). Hemostasis was achieved by applying unipolar coagulation. Intermittent saline irrigation through a fine catheter in the working channel was used to clear the surgical field and telescope 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 forceps, the graft was insinuated into the defect a few millimeters, to plug it. The holding forceps were withdrawn gradually by slightly rotating them, and the graft was left in place (Fig. 2C). This was supported 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. Intermittent lumbar drainage of CSF was done twice a day for 3 to 5 days. Nasal packing was removed

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48 to 72 hours after surgery. Patients were advised to avoid straining and nose blowing during the immediate postoperative period.

RESULTS The rhinorrhea resolved completely in eight patients. One case of post-traumatic rhinorrhea recurred a month later but responded to conservative treatment. There were no procedure-related complications. Transient anosmia occurred in two patients but recovered spontaneously within a month.

DISCUSSION Most neurosurgeons prefer the intracranial approach.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 intracranial 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 approach has ranged from 20 to 40%.7,17,18 In contrast, extracranial approaches have lower morbidity rates, higher success rates, and seldom 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, the cribriform plate, and the fovea ethmoidalis.6,16,1921 Transnasal endoscopic surgery minimizes intranasal trauma and preserves the bony framework supporting the frontal recess and other critical areas.22 Mostly otolaryngologists use a 4-mm sinoscope 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 working sheath, which is fixed with an Endoscope Holder, eliminates unwanted movement and frees both hands for surgical maneuvering. Working channels in the sheath allow other instrumentation to be inserted without causing injury. The field and lens can also be irrigated when obscured by bleeding 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, phenolsulfonphthalein, indigo carmine, and fluorescein have been used to demonstrate the osculum of the fistula.23,24 Fluorescein is still in use but is not preferred because it is associated with complications like transverse myelitis and allergic reactions.25 The Valsalva maneuver has been used to detect ambiguous 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 substitute 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 pedicled 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 further reinforcement by fibrin glue, thereby reducing the cost of treatment. 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 working sheath is relatively inexpensive, effective, safe, and less traumatic.

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REFERENCES
1. Hao SP. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea: an interposition technique. Laryngoscope 1996;106:501503 2. Ommaya AK, Di Chiro G, Baldwin M, Pennybacker JB. Nontraumatic cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry 1968;31:214225 3. Spetzler RF, Wilson CB. Management of recurrent CSF rhinorrhoea of the middle and posterior fossa. J Neurosurg 1978;49:393397 4. Westmore GA, Whittam ED. Cerebrospinal fluid rhinorrhoea and its management. Br J Surg 1982;69:489492 5. Ray BS, Bergland RM. Cerebrospinal fluid fistula: clinical aspects, techniques of localization and methods of closure. J Neurosurg 1967;30:399405 6. Calcaterra TC. Extracranial surgical repair of cerebrospinal fluid rhinorrhoea. Ann Otol Rhinol Laryngol 1980;89: 108116 7. Park JI, Strelzow VV, Friedman WH. Current management of cerebrospinal fluid rhinorrhoea. Laryngoscope 1983;93:12941300 8. Yessenow RS, McCabe BF. The osteo-cutaneous flap in repair of cerebrospinal fluid rhinorrhoea: a 20-year experience. Otolaryngol Head Neck Surg 1989;101:555558 9. Zeitouni AG, Frenkiel S, Mohr. Endoscopic repair of anterior skull base cerebrospinal fluid fistulas: an emphasis on postoperative nasal function maximization. J Otolaryngol 1994;23:225227 10. Wigand WE. Transnasal ethmoidectomy under endoscopic control. Rhinology 1981;19:715 11. Mattox DE, Kennedy DW. Endoscopic management of cerebrospinal fluid leaks and cephaloceles. Laryngoscope 1990;100:857862 12. Dodson EE, Gross CW, Swerdloff JL, Gustafson LM. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea and skull base defect: a review of twenty-nine cases. Otolaryngol Head Neck Surg 1994;111:600605 13. Stankiewicz JA. Cerebrospinal fluid fistula and endoscopic sinus surgery. Laryngoscope 1991;101:250256 14. Ommaya AK. Spinal fluid fistulae. Clin Neurosurg 1976; 23:363392 15. Hirsch O. Successful closure of cerebrospinal fluid rhinorrhoea by endonasal surgery. Arch Otolaryngol 1952;56: 113 16. McCormack B, Cooper PR, Persky M, Rothstein S. Extracranial repair of cerebrospinal fluid fistulas: technique and results in 37 patients. Neurosurgery 1990;27:412417 17. Aarabi B, Leibrock LG. Neurosurgical approaches to cerebrospinal fluid rhinorrhoea. Ear Nose Throat J 1992;71: 300305 18. Hubbard JL, McDonald TJ, Pearson BW, Laws ER. Spontaneous cerebrospinal fluid rhinorrhoea: evolving concepts in diagnosis and surgical management based on the Mayo Clinic experience from 1970 through 1981. Neurosurgery 1985;16:314321

19. Briant TDR, Snell E. Diagnosis of cerebrospinal rhinorrhoea and the rhinologic approach to its repair. Laryngoscope 1976;77:13901409 20. McCabe BF. The osteo-mucoperiosteal flap in repair of cerebrospinal fluid rhinorrhoea. Laryngoscope 1976;86:537 539 21. Montgomery WW. Surgery of cerebrospinal fluid rhinorrhoea and otorrhoea. Arch Otolaryngol 1966;84:92104 22. Schaefer SD, Manning S, Close LG. Endoscopic paranasal sinus surgery: indications and considerations. Laryngoscope 1989;99:15 23. Strauss H. Fluorescein als indikator fuer die Nierenfunktion. Klin Wochenschr 1913;50:22262227 24. Fox N. Cure in a case of cerebrospinal rhinorrhoea. Arch Otolarynogol Head Neck Surg 1933;17:8586 25. Mahaley MS, Odom GL. Complications following intracranial injections of fluorescein. J Neurosurg 1966;25: 298299 26. Bibas AG, Skia B, Hickey SA. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea. Br J Neurosurg 2000;14:4952 27. Lanza DC, OBrien DA, Kennedy DW. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope 1996;106:11191125 28. Roberts GA, Foy PM, Bolger C. Idiopathic spontaneous cerebrospinal fluid rhinorrhoea and pneumocephalus: case report and literature review. Br J Neurosurg 1996;10:513517 29. Shaffrey CI, Spotnitz WD, Shaffrey NE, Jane JA. Neurosurgical applications of fibrin glue: augmentation of dural closure in 134 patients. Neurosurgery 1990;26:207210

Commentary
his article reviewed the endoscopic management of cerebrospinal fluid (CSF) leaks, a technique that has been used since the 1980s. The authors 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 otolaryngologists. At many hospitals, it is the first-line treatment offered for a CSF leak from the skull base judged to be reachable with an endoscope. It is reasonable to use the technique, rather than intracranial 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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dure and is performed on an outpatient basis with local anesthesia and intravenous sedation. In experienced hands, the morbidity rate is minimal. Ian T. Jackson, M.D.1

Commentary
he authors report nine patients who underwent endoscopic repair of a cerebrospinal fluid (CSF) leak. They achieved excellent results using a much less invasive approach than a traditional bifrontal craniotomy. We prefer to use septal or conchal cartilage to

fill the defect. We also use temporalis fascia. We have not used fluorescein dye and have been able to visualize CSF leakage without difficulty. Furthermore, the use 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. 1Institute for Craniofacial and Reconstructive Surgery, Southfield, Michigan. Copyright 2003 by Thieme Medical 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 Neurological Institute, Phoenix, Arizona. Copyright 2003 by Thieme Medical 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.

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