Determinants of Success in Endoscopic Cerebrospinal Fluid Leak Repair

Otolaryngology– Head and Neck Surgery Volume 133 Number 2

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Factors Affecting Blood Loss during Functional Endoscopic Sinus Surgery Edward J Hepworth, MD (presenter); Ankit Patel, MD; Vladimir Nekhendzy, MD; Harry Lemmens, MD; Winston C. Vaughan, MD Menlo Park CA; Indian Head Park IL; Stanford CA; Stanford CA; East Palo Alto CA

Objective: Functional endoscopic sinus surgery (FESS) has become the main therapy for paranasal sinus disease. Bleeding can lead to anatomic disorientation, longer surgical time, packing, and longer recovery. No study has yet quantified the relationship between operative blood loss and interventions made in the preoperative clinical setting. The aim of this study was to evaluate prepoperative factors which may affect intraoperative bleeding. Methods: This was a retrospective review of patients undergoing FESS. Preoperative data included age, gender, infection, polyposis, CT staging, and use of antibiotics and steroids. Intraoperative data included surgical time, blood pressure measurements, complexity of surgery, hematologic data, and total blood loss. Data were then reviewed for statistical comparison by the Wilcoxon test. Results: 143 patients met criteria in this three-year study. The mean blood loss during FESS was 227 cc (median 125, range 25 to 1500 cc). Age and gender did not affect blood loss. There was a strong relationship between intraoperative blood loss and extent of surgery (P ⫽ 0.003) and polyposis (P ⫽ 0.0004). Presence of infection resulted in increased blood loss averaging 75 cc (P ⫽ 0.15). Usage of antibiotics without documented preoperative infection did not improve hemostasis (P ⫽ 0.4). Oral steroids given in the office weeks prior to surgery decreased blood loss in non-polyp and polyp patients by 55 and 72 cc, respectively (P ⫽ 0.68). The amount of steroids did not statistically change blood loss. Conclusion: Infection and antibiotic use in the preoperative period have minimal effect on operative bleeding. Polyposis does affect blood loss, however preoperative oral steroid use does not improve hemostasis in a statistically significant manner. Perioperative morbidity is better minimized by the use of meticulous dissection, efficient surgery, and careful anesthesia. Significance: The two most significant factors in operative blood loss are the extent of surgery and the presence of polyposis. 9:12

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Determinants of Success in Endoscopic Cerebrospinal Fluid Leak Repair Devraj Basu, MD (presenter); Bruce H Haughey, MBChB MS FRACS; James M Hartman, MD Saint Louis MO; Saint Louis MO; Saint Louis MO

Objective: Despite the overall success of endoscopic methods in repairing anterior skull base cerebrospinal fluid (CSF) leaks, limited insight is available into the mechanisms by which these repairs can sometimes fail. Methods: In a retrospective chart review, 24 patients undergoing endoscopic closure of an anterior skull base CSF leaks were analyzed for factors correlating with initial repair outcome. Factors examined included age, sex, body mass index, leak etiology, comorbidities, preoperative studies, successful direct visualization of leak, leak location, defect size, presence of meningocele, repair methods, steroid usage, lumbar drain usage, and usage of postoperative radiation. Results: 13 patients with either spontaneous leaks or iatrogenic leaks arising from FESS were repaired with significantly lower recurrence rate (8%) than 11 patients with leaks induced by skull base procedures (45%). However, in the latter group, only 14% recurred when the dural defect was directly visualized, while leaks always recurred when a bony dehiscence was patched in the absence of a visible dural defect. Such defects were least frequently localized in patients with craniotomy-induced leaks. A trend toward morbid obesity was also noted among repair failures. Conclusion: Direct visualization of the dural defect is essential for endoscopic repair of anterior skull base CSF leaks, with craniotomy-induced leaks being the most challenging to localize. Morbid obesity is a likely factor contributing to failure of endoscopically repaired CSF leaks. Significance: Defining the risk factors for recurrence of anterior skull base CSF leaks after endoscopic repair can not only influence intraoperative methodology but also impact perioperative management. Factors such as craniotomy-induced leaks and obesity may provide a rationale for use in select patients of conservative perioperative measures such as lumbar drains and protracted bed rest. 9:20

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Nationwide Survey on the Use of Image-Guided Functional Endoscopic Sinus Surgery Edward J Hepworth, MD (presenter); Matthew Bucknor, BA; Ankit Patel, MD; Winston C . Vaughan, MD Menlo Park CA; Stanford CA; Indian Head Park IL; East Palo Alto CA

Objective: Image-guidance systems (IGS) in functional endoscopic sinus surgery (FESS) are an emerging technology. The advancement of IGS as a standard-of-care tool has not yet been established. This may be due to many variables including cost recovery, provider opinion regarding benefit, training, and logistics of usage. This study investigated IGS usage via a nationwide survey. Methods: A single-page survey was mailed to all practicing American otolaryngologists registered with the Academy of Otolaryngology—Head and Neck Surgery. Responses in-

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Research Forum—Tuesday P105