- Email: [email protected]
Endonasal endoscopic approach to the anterior skull base for reconstruction of CSF fistulas
International Congress Series 1240 (2003) 931 – 933
Endonasal endoscopic approach to the anterior skull base for reconstruction of CSF fistulas R.V. Moukarbel a, G.F. Haddad b, G. Kahwaji, U. Hadi a,* a
Department of Otolaryngology—Head and Neck Surgery, American University of Beirut, PO BOX: 18th FL 850, 3rd Avenue, New York, NY 10022, USA b Department of Surgery, Division of Neurosurgery, American University of Beirut, New York, NY, USA
1. Introduction Cerebrospinal fluid rhinorhea is a very challenging problem to both the neurosurgeon and the otolaryngologist. When conservative measures fail to control this condition, surgical repair becomes mandatory [1]. Surgical repair may be achieved transcranially through a formal craniotomy approach and extracranially through an external ethmoidectomy or transnasally using endoscopic surgical techniques. Endoscopic transnasal repair of CSF leaks has been more and more popular due to its significantly decreased surgical morbidity as compared to the other surgical techniques [2]. We hereby present our experience with the repair of such defects in the anterior skull base by reviewing our series that included 16 cases repaired endoscopically.
2. Materials and methods We conducted a chart review of all the patients who underwent transnasal endoscopic CSF leak repair in our institution since 1993. Several parameters were evaluated including the etiology of the leak, the defect site, diagnostic imaging studies and the type of graft used. Success was defined as absence of leak up to the time of this report.
3. Results After conducting a thorough review, we found 16 cases overall among which there was 11 males and 5 females with an age ranging from 30 to 66 years. The cause of the leak was * Corresponding author. Fax: +1-96-113-70793. E-mail address: [email protected] (U. Hadi). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00739-8
932
R.V. Moukarbel et al. / International Congress Series 1240 (2003) 931–933
determined to be spontaneous in three patients, iatrogenic in nine patients of whom five were noted after a FESS procedure, one after an SMR procedure that was complicated by violation of the sphenoid sinus and three after a Transsphenoidal Resection of the Pituitary procedure. Traumatic base of skull injuries were noted in four patients only. The crack was well identified in all cases except for one. The fovea ethmoidalis was violated in nine cases, the posterior ethmoid in two cases, five cases involved the sphenoid sinus and in three cases the cribriform plate was violated. The duration of the leak varied from immediate (intraop) to 2 years in our series. To note that one case of iatrogenic cause was identified intraoperatively during a FESS procedure and was repaired immediately. The leak was left sided in eight cases and right sided in five cases and bilateral in three cases. The follow-up period ranged from 3 months to 9 years. In our series, no failure was noted except in one case, which showed a recurrence 1 year later. This recurrent case was repaired subsequently through a frontal craniotomy approach with success.
4. Discussion In 1926, Dandy reported the first intracranial repair of CSF rhinorhea through a bifrontal craniotomy [3]. This approach remained the standard surgical procedure until 1948 when Dohlman introduced his extracranial approach [4]. It was not until 1981 that transnasal endoscopic surgical techniques were used by Wigand [5] to repair CSF rhinorhea. This approach significantly decreased the morbidity and cost of the surgical repair. The use of rigid scopes allows excellent visualization of the leaking site with subsequent ease of repair. Several reports in the literature attempted to review such a kind of repair proving it to have excellent success rates. With the advent of FESS surgery, CSF rhinorhea was encountered more and more by the otolaryngologists. Detecting and repairing such a leak is of paramount importance in order to reduce the risk of developing meningitis with all its devastating possible sequelae. Patients with CSF rhinorhea can present with various signs and symptoms including headache, isolated rhinorhea and anosmia among others [6]. Proper diagnosis may start with simple biochemical testing. Glucose level frequently gives a false positive result. In addition, a negative result does not rule out CSF leak. Beta-2 transferin is a much more reliable test with a high sensitivity and specificity but it is not widely available. Imaging modalities can be used to localize a defect in the skull base thus helping to confirm the diagnosis and also providing clear surgical landmarks for the repair. These modalities include CT scan, MRI and CT cisternography with Metrizamide [7]. In our series, imaging modalities included mainly CT with Metrizamide. The site was localized in 10 patients. In the remaining cases, it was not done for variable reasons (refused or cannot afford or intraop repair). The site of the leak was noted to be quite variable in most series. The anterior ethmoid and the cribriform plate were noted to be the most common in many series [6 –8]. In our series the fovea ethmoidalis was the most common site being involved in nine cases. Very few reports in the literature reviewed CSF rhinorhea management with emphasis on sphenoidal defects [9]. Our series included five cases in which the defect was localized in the sphenoid sinus. The surgical technique for correcting sphenoidal sinus defects did not vary from other
R.V. Moukarbel et al. / International Congress Series 1240 (2003) 931–933
933
sites. However, the use of fat obliteration was followed in all cases. The materials used to repair the defect included free tissue grafts and pedicled grafts. We adopted a standard technique whereby we applied temporalis fascia and muscle to all our patients. This was reinforced with fibrin glue in all of the cases and with fat in addition in many cases. Nasal packing was used to hold the material in position and removed gradually over few days. The necessity of lumbar drain use is controversial according to many series [10]. It was used in three of our patients and removed in 2 to 5 days. In the series by Casiano and Jassir [10], it was postulated that endoscopic repair of smaller defects can be performed safely without lumbar drain placement in the absence of intracranial trauma and resection of large skull base lesions. Our series showed a high success rate with only one failure detected among our 16 cases. All the remaining cases were repaired using a single surgical procedure. This proves the efficacy of endoscopic transnasal repair.
5. Conclusion Endosopic transnasal repair of skull base defects is an excellent technique to close CSF fistulas thus avoiding its life-threatening complications. This approach is less morbid than the other described approaches and has the distinguishing advantage that, in cases of failure, a second endoscopic repair can be attempted safely and easily. It is our belief that the transnasal endoscopic approach should be the first surgical technique used in an attempt to repair an anterior skull base defect in view of its high success rate and minimal morbidity.
References [1] V.H. Mao, et al., Endoscopic repair of cerebrospinal fluid rhinorhea, Otolaryngol Head and Neck Surgery 122 (2000) 56 – 60. [2] J.L. Zweig, et al., Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success, Otolaryngol Head and Neck Surgery 123 (2000) 195 – 201. [3] W.D. Dandy, Pneumocephalus (intracranial pneumocele or aerocele), Archives of Surgery 12 (1926) 949 – 982. [4] G. Dohlman, Spontaneous cerebrospinal fluid rhinorhea, Acta Otolaryngologica, Supplement 67 (1948) 20 – 23. [5] M.E. Wigand, Transnasal ethmoidectomy under endoscopic control, Rhinology 19 (1981) 7 – 15. [6] E.E. Dodson, et al., Transnasal endoscopic repair of cerebrospinal fluid rhinorhea and skull base defects: a review of twenty-nine cases, Otolaryngol Head and Neck Surgery 111 (1994) 600 – 605. [7] M.K. Wax, et al., Contemporary management of cerebrospinal fluid rhinorhea, Otolaryngol Head and Neck Surgery 116 (1997) 442 – 449. [8] K.-I. Hisamatsu, et al., Spontaneous cerebrospinal fluid rhinorhea through the cribriform plate fistula cured by endonasal surgery, Otolaryngol Head and Neck Surgery 113 (1995) 822 – 825. [9] N.H. Mehendale, et al., Management of sphenoid sinus cerebrospinal fluid rhinorhea: making use of and extended approach to the sphenoid sinus, Otolaryngol Head and Neck Surgery 126 (2002) 147 – 153. [10] R.R. Casiano, D. Jassir, Endoscopic cerebrospinal fluid rhinorhearepair: is a lumbar drain necessary, Otolaryngol Head and Neck Surgery 121 (1999) 745 – 750.
Endonasal endoscopic approach to the anterior skull base for reconstruction of CSF fistulas R.V. Moukarbel a, G.F. Haddad b, G. Kahwaji, U. Hadi a,* a
Department of Otolaryngology—Head and Neck Surgery, American University of Beirut, PO BOX: 18th FL 850, 3rd Avenue, New York, NY 10022, USA b Department of Surgery, Division of Neurosurgery, American University of Beirut, New York, NY, USA
1. Introduction Cerebrospinal fluid rhinorhea is a very challenging problem to both the neurosurgeon and the otolaryngologist. When conservative measures fail to control this condition, surgical repair becomes mandatory [1]. Surgical repair may be achieved transcranially through a formal craniotomy approach and extracranially through an external ethmoidectomy or transnasally using endoscopic surgical techniques. Endoscopic transnasal repair of CSF leaks has been more and more popular due to its significantly decreased surgical morbidity as compared to the other surgical techniques [2]. We hereby present our experience with the repair of such defects in the anterior skull base by reviewing our series that included 16 cases repaired endoscopically.
2. Materials and methods We conducted a chart review of all the patients who underwent transnasal endoscopic CSF leak repair in our institution since 1993. Several parameters were evaluated including the etiology of the leak, the defect site, diagnostic imaging studies and the type of graft used. Success was defined as absence of leak up to the time of this report.
3. Results After conducting a thorough review, we found 16 cases overall among which there was 11 males and 5 females with an age ranging from 30 to 66 years. The cause of the leak was * Corresponding author. Fax: +1-96-113-70793. E-mail address: [email protected] (U. Hadi). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00739-8
932
R.V. Moukarbel et al. / International Congress Series 1240 (2003) 931–933
determined to be spontaneous in three patients, iatrogenic in nine patients of whom five were noted after a FESS procedure, one after an SMR procedure that was complicated by violation of the sphenoid sinus and three after a Transsphenoidal Resection of the Pituitary procedure. Traumatic base of skull injuries were noted in four patients only. The crack was well identified in all cases except for one. The fovea ethmoidalis was violated in nine cases, the posterior ethmoid in two cases, five cases involved the sphenoid sinus and in three cases the cribriform plate was violated. The duration of the leak varied from immediate (intraop) to 2 years in our series. To note that one case of iatrogenic cause was identified intraoperatively during a FESS procedure and was repaired immediately. The leak was left sided in eight cases and right sided in five cases and bilateral in three cases. The follow-up period ranged from 3 months to 9 years. In our series, no failure was noted except in one case, which showed a recurrence 1 year later. This recurrent case was repaired subsequently through a frontal craniotomy approach with success.
4. Discussion In 1926, Dandy reported the first intracranial repair of CSF rhinorhea through a bifrontal craniotomy [3]. This approach remained the standard surgical procedure until 1948 when Dohlman introduced his extracranial approach [4]. It was not until 1981 that transnasal endoscopic surgical techniques were used by Wigand [5] to repair CSF rhinorhea. This approach significantly decreased the morbidity and cost of the surgical repair. The use of rigid scopes allows excellent visualization of the leaking site with subsequent ease of repair. Several reports in the literature attempted to review such a kind of repair proving it to have excellent success rates. With the advent of FESS surgery, CSF rhinorhea was encountered more and more by the otolaryngologists. Detecting and repairing such a leak is of paramount importance in order to reduce the risk of developing meningitis with all its devastating possible sequelae. Patients with CSF rhinorhea can present with various signs and symptoms including headache, isolated rhinorhea and anosmia among others [6]. Proper diagnosis may start with simple biochemical testing. Glucose level frequently gives a false positive result. In addition, a negative result does not rule out CSF leak. Beta-2 transferin is a much more reliable test with a high sensitivity and specificity but it is not widely available. Imaging modalities can be used to localize a defect in the skull base thus helping to confirm the diagnosis and also providing clear surgical landmarks for the repair. These modalities include CT scan, MRI and CT cisternography with Metrizamide [7]. In our series, imaging modalities included mainly CT with Metrizamide. The site was localized in 10 patients. In the remaining cases, it was not done for variable reasons (refused or cannot afford or intraop repair). The site of the leak was noted to be quite variable in most series. The anterior ethmoid and the cribriform plate were noted to be the most common in many series [6 –8]. In our series the fovea ethmoidalis was the most common site being involved in nine cases. Very few reports in the literature reviewed CSF rhinorhea management with emphasis on sphenoidal defects [9]. Our series included five cases in which the defect was localized in the sphenoid sinus. The surgical technique for correcting sphenoidal sinus defects did not vary from other
R.V. Moukarbel et al. / International Congress Series 1240 (2003) 931–933
933
sites. However, the use of fat obliteration was followed in all cases. The materials used to repair the defect included free tissue grafts and pedicled grafts. We adopted a standard technique whereby we applied temporalis fascia and muscle to all our patients. This was reinforced with fibrin glue in all of the cases and with fat in addition in many cases. Nasal packing was used to hold the material in position and removed gradually over few days. The necessity of lumbar drain use is controversial according to many series [10]. It was used in three of our patients and removed in 2 to 5 days. In the series by Casiano and Jassir [10], it was postulated that endoscopic repair of smaller defects can be performed safely without lumbar drain placement in the absence of intracranial trauma and resection of large skull base lesions. Our series showed a high success rate with only one failure detected among our 16 cases. All the remaining cases were repaired using a single surgical procedure. This proves the efficacy of endoscopic transnasal repair.
5. Conclusion Endosopic transnasal repair of skull base defects is an excellent technique to close CSF fistulas thus avoiding its life-threatening complications. This approach is less morbid than the other described approaches and has the distinguishing advantage that, in cases of failure, a second endoscopic repair can be attempted safely and easily. It is our belief that the transnasal endoscopic approach should be the first surgical technique used in an attempt to repair an anterior skull base defect in view of its high success rate and minimal morbidity.
References [1] V.H. Mao, et al., Endoscopic repair of cerebrospinal fluid rhinorhea, Otolaryngol Head and Neck Surgery 122 (2000) 56 – 60. [2] J.L. Zweig, et al., Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success, Otolaryngol Head and Neck Surgery 123 (2000) 195 – 201. [3] W.D. Dandy, Pneumocephalus (intracranial pneumocele or aerocele), Archives of Surgery 12 (1926) 949 – 982. [4] G. Dohlman, Spontaneous cerebrospinal fluid rhinorhea, Acta Otolaryngologica, Supplement 67 (1948) 20 – 23. [5] M.E. Wigand, Transnasal ethmoidectomy under endoscopic control, Rhinology 19 (1981) 7 – 15. [6] E.E. Dodson, et al., Transnasal endoscopic repair of cerebrospinal fluid rhinorhea and skull base defects: a review of twenty-nine cases, Otolaryngol Head and Neck Surgery 111 (1994) 600 – 605. [7] M.K. Wax, et al., Contemporary management of cerebrospinal fluid rhinorhea, Otolaryngol Head and Neck Surgery 116 (1997) 442 – 449. [8] K.-I. Hisamatsu, et al., Spontaneous cerebrospinal fluid rhinorhea through the cribriform plate fistula cured by endonasal surgery, Otolaryngol Head and Neck Surgery 113 (1995) 822 – 825. [9] N.H. Mehendale, et al., Management of sphenoid sinus cerebrospinal fluid rhinorhea: making use of and extended approach to the sphenoid sinus, Otolaryngol Head and Neck Surgery 126 (2002) 147 – 153. [10] R.R. Casiano, D. Jassir, Endoscopic cerebrospinal fluid rhinorhearepair: is a lumbar drain necessary, Otolaryngol Head and Neck Surgery 121 (1999) 745 – 750.