neuroendoscopic transnasal repair of

7/30/2019 Neuroendoscopic Transnasal Repair Of

1/6

ORIGINA L ARTICLE

737373

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


2/6

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.


3/6

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


4/6


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.


5/6

NEUROENDOSCOPIC TRANSNASAL REPAIR OF CSF RHINORRHEA/HUSAIN ET AL 77

REFERENCES

1. Hao SP.Transnasal endoscopic repair of cerebrospinal fluid

rhinorrhoea: an interposit ion technique. Laryngoscope1996;106:501503

2. Ommaya AK, Di Chiro G, Baldwin M, Pennybacker JB.Nontraumati c cerebrospinal fluid rhinorrhoea. J NeurolNeurosurg Psychiatry 1968;31:214225

3. Spetzler RF, Wilson CB. M anagement of recurrent CSFrhinorrhoea of the middle and posterior fossa. J Neurosurg1978;49:393397

4. Westmore GA, W hittam ED. Cerebrospinal fluid rhinor-rhoea and i ts management. Br J Surg 1982;69:489492

5. Ray BS, Bergland RM . Cerebrospinal fluid fistula: clinicalaspects, techniques of locali zation 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 manage-ment of cerebrospinal fluid rhinorrhoea. Laryngoscope1983;93:12941300

8. Yessenow RS, M cCabe BF.The osteo-cutaneous fl ap in re-pair of cerebrospinal f luid rhinorrhoea: a 20-year experi-ence. Otolaryngol H ead Neck Surg 1989;101:555558

9. Zeitouni AG, Frenkiel S, M ohr.Endoscopic repair of ante-rior skull base cerebrospinal fluid f istulas: an emphasis onpostoperati ve nasal function maximization. J Otolaryngol1994;23:225227

10. Wigand WE. Transnasal ethmoidectomy under endo-scopic control. Rhinology 1981;19:715

11. M attox DE, Kennedy DW. Endoscopic management ofcerebrospinal fluid leaks and cephaloceles. Laryngoscope1990;100:857862

12. Dodson EE, Gross CW, Swerdloff JL, Gustafson LM .Transnasal endoscopic repair of cerebrospinal fluid rhinor-rhoea and skull base defect: a review of twenty-nine cases.Otolaryngol H ead Neck Surg 1994;111:600605

13. Stankiewicz JA. Cerebrospinal fluid fistula and endoscopicsinus surgery. Laryngoscope 1991;101:250256

14. Ommaya AK. Spinal fluid fistulae. Clin Neurosurg 1976;23:363392

15. Hirsch O. Successful closure of cerebrospinal fluid rhinor-rhoea by endonasal surgery.Arch Otolaryngol 1952;56: 113

16. M cCormack B, Cooper PR, Persky M , Rothstein S. Ex-tracranial repair of cerebrospinal fluid fistulas: techniqueand results in 37 patients. Neurosurgery 1990;27:412417

17. Aarabi B, Leibrock LG. Neurosurgical approaches to cere-brospinal fluid rhinorrhoea. Ear Nose Throat J 1992;71:300305

18. Hubbard JL, M cDonald TJ, Pearson BW, Laws ER. Spon-taneous cerebrospinal fluid rhinorrhoea: evolving conceptsin diagnosis and surgical management based on the MayoClini c experience from 1970 through 1981. Neurosurgery1985;16:314321

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

24. Fox N. Cure in a case of cerebrospinal rhinorrhoea. ArchOtolarynogol H ead Neck Surg 1933;17:8586

25. M ahaley MS, Odom GL . Complications following in-tracranial injections of fluorescein. J Neurosurg 1966;25:

29829926. Bibas AG, Skia B, H ickey SA. Transnasal endoscopic re-

pair of cerebrospinal fluid rhinorrhoea. Br J Neurosurg2000;14:4952

27. Lanza DC, OBrien DA, Kennedy DW. Endoscopic repairof cerebrospinal fluid fistulae and encephaloceles. Laryn-goscope 1996;106:11191125

28. Roberts GA, Foy PM, Bolger C. Idiopathic spontaneouscerebrospinal fluid rhinorrhoea and pneumocephalus: casereport and li terature review.Br J Neurosurg 1996;10:513517

29. Shaffrey CI, Spotnitz WD, Shaffrey NE, Jane JA. Neuro-surgical applications of fi brin glue: augmentation of duralclosure in 134 patients. Neurosurgery 1990;26:207210

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-


6/6


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.

neuroendoscopic transnasal repair of

Documents