Endoscopic transnasal management of cerebrospinal fluid leaks of the sphenoid sinus

doi:10.1016/j.jcms.2009.10.013

Journal of Cranio-Maxillofacial Surgery

Volume 38, Issue 5, July 2010, Pages 396-402

https://doi.org/10.1016/j.jcms.2009.10.013 Get rights and content

Summary

The authors reviewed the medical records of patients who had undergone endoscopic management of sphenoid sinus (SS) cerebrospinal fluid (CSF) leaks in our department between 2005 and 2007. Eight patients were included in this study: 4 males and 4 females. CSF fistulae were due to trauma, surgery, and some were idiopathic. In all the patients, a multilayer skull base closure was performed. No SS obliteration was carried out. One patient required revision surgery for persistent CSF leak. Multilayer skull base closure is confirmed as the preferred option in sphenoid CSF leaks. The limited morbidity and high success rate fit well with the data in the literature and make this treatment option advisable.

Introduction

CSF leaks result from an abnormal communication between the subarachnoid space and the extracranial space. Because of the risk of complications (Bernal-Sprekelsen et al., 2005), any persistent CSF leak should be repaired. Of all the CSF leaks, those from the sphenoid sinus (SS) represent a unique challenge due to the anatomical relationship and the extreme variability in the shape of the sinus itself. Transcranial approaches are associated with significant morbidity on one hand and with mortality on the other, and the results are not altogether satisfactory. Based on the cutting edge intuition of Hirsch (Hirsch, 1952), endonasal management has become the standard treatment in these cases. Microscopic approaches give a reduced field of view (Aydin et al., 2007), the lateral walls of the SS are just not sufficiently well seen. In recent years, endoscopic techniques have gained popularity given their ability to look around the corner and the limited morbidity entailed. Success rates are higher than with traditional approaches, especially when evaluating CSF leaks of the lateral recess.

The aim of this paper is to add our experience to the body of published data on this discussed topic and to confirm the feasibility, tolerability and effectiveness of such techniques in the management of SS CSF leaks.

Section snippets

Materials and methods

We retrospectively reviewed the medical records of 8 patients who had undergone transnasal endoscopic repair of CSF fistulae of the SS with multilayer skull base closure. Patients with CSF fistulae involving other sites or treated with different techniques (i.e. sinus obliteration) were excluded from the study. Clinical data were analysed for the characteristics of the patients and of their fistulae, the surgical technique and materials used for the repair, the peri-operative management, and

Results

In 7 patients (87.5%), the CSF leak was successfully repaired at the first attempt. One patient, affected with a MEC in the lateral recess, required a second surgical procedure during the same period in hospital due to persistence of rhinorrhoea after removal of the nasal swabs. Therefore, the overall rate of successful repair was 100%. No surgical complications were encountered in any of the patients.

Follow-up (FU) ranged from 10 to 40 months (mean 20.6 ± 9.9 SD months). At the time of writing,

Discussion

Cerebrospinal fluid leaks of the SS are challenging conditions with different aetiologies. Trauma-related cases have been considered the most frequent in recent years (McCormack et al., 1990, Zeitouni et al., 1994, Hughes et al., 1997, Nachtigal et al., 1999, Mao et al., 2000), but this is not confirmed in our series, even though it is small.

In agreement with other authors (Lopatin et al., 2003), we maintain that spontaneous CSF fistulae are not so rare as previously thought. In our series, in

Conclusions

The endoscopic transnasal management of SS CSF leaks is a safe and well-tolerated procedure that in the hands of experienced surgeons allows the repair of skull base defects with minimal morbidity. The trans-pterygoid approach permits the successful treatment of lesions in the lateral sphenoidal recess that previously would have required an external neurosurgical approach. Sinus obliteration should be performed after multiple failures with multilayer closure, or when a multilayer closure is not

Conflict of interest

All the authors certify that they have no potential conflicts of interest with any entity mentioned in this manuscript, and that they received no specific financial support for this work.

References (29)

H. Bächli et al.
Skull base and maxillofacial fractures: two centre study with correlation of clinical findings with a comprehensive craniofacial classification system
J Craniomaxillofac Surg
(2009)
W.E. Bolger
Endoscopic transpterygoid approach to the lateral sphenoid recess: surgical approach and clinical experience
Otolaryngol Head Neck Surg
(2005)
R.R. Casiano et al.
Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?
Otolaryngol Head Neck Surg
(1999)
V.H. Mao et al.
Endoscopic repair of cerebrospinal fluid rhinorrhea
Otolaryngol Head Neck Surg
(2000)
M.K. Wax et al.
Contemporary management of cerebrospinal fluid rhinorrhea
Otolaryngol Head Neck Surg
(1997)
J.L. Zweig et al.
Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success
Otolaryngol Head Neck Surg
(2000)
V.K. Anand et al.
Surgical decisions in the management of cerebrospinal fluid rhinorrhea
Rhinology
(1995)
S. Aydin et al.
The endoscopic endonasal trans-sphenoidal approach to the sellar and suprasellar area. Anatomic study
J Neurosurg Sci
(2007)
M. Bernal-Sprekelsen et al.
Closure of cerebrospinal fluid leaks prevents ascending meningitis
Rhinology
(2005)
M. Buchfelder et al.
Intrasphenoidal encephalocele – a clinical entity
Acta Neurochir
(1987)

J.A. Burns et al.

Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up

Laryngoscope

(1996)

T.C. Calcaterra

Extracranial surgical repair of cerebrospinal rhinorrhea

Ann Otol Rhinol Laryngol

(1980)

P. Castelnuovo et al.

Endonasal endoscopic repair of Sternberg's canal cerebrospinal fluid leaks

Laryngoscope

(2007)

L. Castillo et al.

Nasal endoscopic repair of cerebrospinal fluid rhinorrhea

Rhinology

(1999)

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Endoscopic transnasal management of cerebrospinal fluid leaks of the sphenoid sinus

Summary

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Conflict of interest

J Craniomaxillofac Surg

Otolaryngol Head Neck Surg

Otolaryngol Head Neck Surg

Otolaryngol Head Neck Surg

Otolaryngol Head Neck Surg

Otolaryngol Head Neck Surg

Surgical decisions in the management of cerebrospinal fluid rhinorrhea

Rhinology

The endoscopic endonasal trans-sphenoidal approach to the sellar and suprasellar area. Anatomic study

J Neurosurg Sci

Closure of cerebrospinal fluid leaks prevents ascending meningitis

Rhinology

Intrasphenoidal encephalocele – a clinical entity

Acta Neurochir

Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up

Laryngoscope

Extracranial surgical repair of cerebrospinal rhinorrhea

Ann Otol Rhinol Laryngol

Endonasal endoscopic repair of Sternberg's canal cerebrospinal fluid leaks

Laryngoscope

Nasal endoscopic repair of cerebrospinal fluid rhinorrhea

Rhinology