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|Year : 2014 | Volume
| Issue : 5 | Page : 532-539
Endoscopic management of CSF rhinorrhea
Rajesh Reddy Sannareddy1, K Rambabu2, Vinay EC Kumar2, Ratnam Boola Gnana1, Alok Ranjan1
1 Department of Neurosurgery, Apollo Health City, Hyderabad, Andhra Pradesh, India
2 Department of Otorhinolaryngology, Apollo Health City, Hyderabad, Andhra Pradesh, India
|Date of Submission||28-Jul-2014|
|Date of Decision||07-Aug-2014|
|Date of Acceptance||03-Oct-2014|
|Date of Web Publication||12-Nov-2014|
Rajesh Reddy Sannareddy
Department of Neurosurgery, Apollo Institute of Neurosciences, Apollo Health City, Jubilee Hills, Hyderabad - 500 096, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Transnasal endoscopic repair has become the treatment of choice for most anterior cranial and all sphenoid sinus breaches. The aim of this paper is to evaluate the results of endoscopic management of cerebrospinal fluid (CSF) rhinorrhea in a tertiary care center in South India. Materials and Methods: A retrospective analysis of 40 consecutive patients who underwent endoscopic repair of CSF rhinorrhea between 2010 and 2013 was performed. Endoscopic procedure consisted of defining the defect and removal of mucosa for 3-4 mm surrounding it. Repair was done using septal cartilage (for defects involving sphenoid sinus where sinus was packed with fat), fascia lata, oxidized cellulose, and fibrin sealant. Lumbar drain was placed for 2-4 days in selected cases. A lumbar-peritoneal shunt was inserted in patients with spontaneous CSF rhinorrhea and high opening lumbar CSF pressure. Results: Spontaneous CSF leaks were more common in middle-aged females, whereas posttraumatic CSF leaks were common in young adult males. The success rates following first surgery for patients with posttraumatic, spontaneous, and postprocedural CSF leaks were 85.7, 81.8, and 75%, respectively, which improved to 95.7, 100, and 100% following second procedure, respectively. Technical failures, poor graft uptake because of radiation therapy, location of leak in the lateral sphenoid recess, lumbar peritoneal shunt malfunction, and poor healing of skull base fractures were responsible for recurrence of leak. Conclusion: Team work between neurosurgeons and otorhinolaryngologists with attention to identification of site of leak, preparation of graft bed, securing the graft in place, and postoperative care is critical to achieve a high level of success for endoscopic repair of CSF rhinorrhea.
Keywords: Cerebrospinal fluid rhinorrhea, endoscopy, surgical repair
|How to cite this article:|
Sannareddy RR, Rambabu K, Kumar VE, Gnana RB, Ranjan A. Endoscopic management of CSF rhinorrhea. Neurol India 2014;62:532-9
| » Introduction|| |
Cerebrospinal fluid (CSF) rhinorrhea is a result of breakdown of physiological barriers that separate the subarachnoid space and the nasal cavity. Surgical repair is required to prevent life-threatening complications, such as meningitis and brain abscess, that can otherwise be seen in 10-40% of patients during follow-up.  Endoscopic repair has become increasingly popular ever since Wigand reported the first endoscopic repair of CSF leak in 1981.  The excellent illumination, stereoscopic view of anatomical details of the skull base, lack of morbidity associated with craniotomy and documented success rates of >90% in expert hands have made transnasal endoscopic repair the procedure of choice for most anterior cranial fossa and sphenoid sinus CSF leaks.  Unlike the intracranial approach, the endoscopic approach provides better illumination and higher success rates with minimal morbidity. ,,, The objective of this study was to analyze the results of endoscopic management of CSF rhinorrhea by a team of neurosurgeons in collaboration with otorhinolaryngologists.
| » Materials and Methods|| |
A retrospective analysis of 40 consecutive patients who underwent endoscopic management for CSF rhinorrhea between 2010 and 2013 was performed. Details pertaining to the etiology of CSF leak, clinical presentation, surgical procedure, and hospital stay were collected. All the patients were followed up in the outpatient department or interviewed over telephone after discharge. Confirmation of CSF rhinorrhea was made by estimating the glucose levels in the watery discharge. Further evaluation included high-resolution computed tomography (CT) scan of paranasal sinuses or magnetic resonance (MR) cisternogram, as was deemed appropriate. In patients with contraindication for MRI, a CT cisternogram was performed. Opening lumbar CSF pressure was measured in patients with spontaneous CSF rhinorrhea. Patients with traumatic CSF rhinorrhea presenting after 48 h underwent CSF analysis to rule out meningitis. All patients with meningitis were treated with intravenous antibiotics for atleast 5 days before surgery.
The initial part of the surgery was performed by an otorhinolaryngologist. Under general anesthesia, nasal mucosa was decongested with infiltration of 1:10,000 adrenaline solution. Rigid Hopkins rod-lens telescopes of 0 and 30° with a 4-mm diameter were used (Karl Storz, Tuttlingen, Germany). Ethmoid sinus leaks were accessed with an ethmoidectomy, cribriform region with a partial middle turbinectomy, and sphenoid sinus through a paraseptal approach via the sphenoid ostium [Figure 1]. After identifying the defect, the graft bed was prepared by removing a cuff of normal mucosa and fibrous tissue off the bone for 3-4 mm surrounding the defect. Bipolar cautery was applied to facilitate repair when arachnoid and dura mater herniated through a bony defect. The repair was performed by a neurosurgeon using fat (harvested from thigh), fascia lata, oxidized cellulose, and fibrin sealant. A piece of nasal septal cartilage was used to cover bony defects of size >1 cm. The nasal pack was placed in the nasal cavity at the end of procedure.
|Figure 1: Illustration of technique of endoscopic repair of CSF leak in patients with cribriform defect (a), ethmoid defect (b). The technique for visualization of sphenoid recess in patients with sphenoid encephaloceles has been illustrated (c). Intraoperative photograph (d) Fascia lata graft being laid over the skull base defect, which has been covered with fat and fibrin sealant after defining the margins of the defect and removal of mucosa around it. CSF = Cerebrospinal fluid|
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The indications for lumbar drain placement were presence of active CSF leak or multiple areas of CSF leak noted intraoperatively, dural defect, encephalocele and bone defect in the skull base > 1 cm. Lumboperitoneal shunt was inserted in patients with spontaneous CSF rhinorrhea having high opening CSF pressure on lumbar puncture. For patients undergoing endoscopic repair for traumatic CSF rhinorrhea, a concomitant repair of frontal sinus was performed by frontal sinusotomy through a supraorbital mini-eyebrow incision when the inner table of frontal sinus was fractured and displaced [Figure 2]. In patients undergoing surgical repair for traumatic CSF rhinorrhea, all sites of skull base fractures noted on preoperative CT scan were carefully inspected intraoperatively for evidence of dural breach or CSF leak.
|Figure 2: Illustration of supraorbital frontal sinusotomy. (a) Skin incision along the medial third of the eyebrow. (b) Elevation of outer table of frontal sinus with a chisel and hammer. (c) Note that the bone flap is not completely detached all around and is still attached to the pericranium on one end. (d) Frontal sinus mucosa is removed; site of CSF leak is identified and repaired with fascia lata, fat and fibrin sealant. (e) Bone flap is replaced and secured to the edges. (f) Pericranium, if replaced over the bone and surgical wound, is closed in layers|
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During the postoperative period, measures were taken to prevent elevation of intracranial pressure, and patients were advised not to blow their nose. Lumbar CSF drainage was performed at 3-5 ml/h until nasal packs were removed on postoperative day 3. The lumbar drain was clamped for the next 24 h and removed if there was no evidence of CSF leak.
The first follow-up visit was scheduled between 2 and 4 weeks after discharge, and subsequent visits were planned per the convenience of the patient. Telephonic interviews were carried out for patients who were not compliant with follow-up.
| » Results|| |
A total of 40 patients underwent the surgical repair during the study period: Traumatic (n = 21), spontaneous (n = 11), and postprocedural or iatrogenic (n = 8). Male gender predilection was noted in the posttraumatic and postprocedural leaks. Spontaneous leaks were more common in female patients (age group 40-59 years) [Table 1]. The incidence of traumatic CSF leaks was highest in young adult males (20-39 years). Most patients presented with a watery discharge from the nostril. Clinical presentation consistent with meningitis was noted in five posttraumatic leaks, two postprocedural leaks, and one spontaneous leak. Postprocedural leaks were observed in five patients following transsphenoidal resection of pituitary adenoma, two patients following resection of clinoidal meningioma, and one patient with orbital adenoid cystic carcinoma.
The most common site of leak in patients with postprocedural CSF leak was sphenoid sinus (seven of eight patients), whereas cribriform and sphenoid were the most common sites of leak in five and four patients with spontaneous CSF leak (n = 11), respectively. In posttraumatic CSF leaks, multiple sites of leaks were frequently observed. A supraorbital frontal sinusotomy through a mini-eyebrow incision was performed in 8 of the 21 posttraumatic leaks for management of associated frontal sinus defect. A concomitant lumbar thecoperitoneal shunt was placed in two patients with spontaneous CSF leak, as the opening CSF pressure was found to be high during routine preoperative evaluation. One patient each in the posttraumatic and postprocedural CSF leak groups underwent lumbar peritoneal shunt placement during the second surgery.
One patient who had recurrence of leak following repair for spontaneous CSF leak had a defect in the lateral sphenoid recess with an associated encephalocele, which was difficult to delineate. Another patient in the same group had lumbar peritoneal shunt malfunction, which caused a CSF leak from a site different from that of the previous surgery. Both patients in the postprocedural group who had CSF leak manifested following radiation therapy for the primary tumor. Of the three failures in the posttraumatic group, two patients had recurrence of leak from the same site, whereas the third one developed a leak from another large defect in the floor of the anterior cranial fossa. All, but one, recurrent leaks were successfully repaired with a second endoscopic approach. Of the seven failures, CSF leak was noted in four of them during the primary admission. The other patients became symptomatic 5, 17, and 23 months following the first surgical repair. No morbidity or mortality related to the surgical procedure was noted in our series.
| » Discussion|| |
In this series, the incidence of posttraumatic CSF leaks was higher than spontaneous and postprocedural leaks, which was in contrast to the results of meta-analysis where the prevalence of spontaneous leaks was high. , Posttraumatic leaks were more common in males aged 20-39 years, whereas spontaneous leaks were more common in females aged 40-59 years. Sphenoid and cribriform plate were the commonest sites for spontaneous CSF leaks, whereas posttraumatic patients had CSF leaks from multiple sites, with cribriform plate and sphenoid being common sites in majority of them. ,,,,,,,, Hence, it is important to inspect all sites corresponding to skull base fractures for evidence of dural breach or CSF leak in patients presenting with traumatic CSF rhinorrhea.
The key to endoscopic transnasal surgical repair of the leak is accurate preoperative location of the site of leak, meticulous preparation of the recipient bed, and accurate placement of the graft material. , In their meta-analysis, Hegazy et al., found no statistically significant difference among different grafting techniques and materials.  In our series, repair of the skull base defect was performed with fat, fascia lata, oxidized cellulose, and fibrin sealant. A piece of nasal septal cartilage was used to cover sphenoid ostia after packing the sinus with fat and fibrin glue.
The efﬁcacy of ﬁbrin glue in preventing CSF leaks remains controversial. Although histopathological studies suggest that ﬁbrin glue may trigger an inﬂammatory response that may promote healing, studies have reported a success rate of 97% with fibrin glue and 92-100% without glue. ,,,,, Mohindra et al., evaluated CSF leaks in 27 pediatric patients and found no statistically significant difference in outcome of endoscopic repairs with or without fibrin glue.  Rodney et al., suggested that if tissue adhesives are used, they must be applied conservatively because a thick layer of adhesive may prevent the graft material from coming in contact with the wound bed. 
Several authors have reported successful results with relatively consistent use of lumbar drain, whereas others have reported similar results without lumbar drain placement. ,, On the basis of a meta-analysis of 14 studies comprising 289 CSF fistulae repairs, Hegazy et al., advocated the use of lumbar drains for 3-5 days with idiopathic leaks, posttraumatic leaks, leaks associated with large defect (>15 mm), recurrent leaks, and leaks associated with a meningocele.  Our indication for lumbar drain placement in 80% of our patients was justified on the basis of the criteria suggested by Hegazy et al.
In a meta-analysis of 55 studies involving 1,778 fistula repairs, Psaltis et al., observed a success rate of 90.6% following first endoscopic repair for CSF rhinorrhea, which improved to 96.6% following a second endoscopic procedure.  The success rate in the largest series of endoscopic repair of CSF leaks reported by Kirtane et al., was 96.63% following first surgery and 98.88% after revision surgery [Table 2].  Castelnuovo et al., reviewed the literature for 286 endoscopic CSF leak repairs and found 28 cases of failure at the first attempt. Most authors, however, failed to specify the precise site of failure and did not offer any further details. From their experience of failures, it emerged that meticulous technique with accurate preparation of the margins and graft coverage of at least 5 mm from the margins was important.  Factors that might predispose to failure of the treatment are the inability to identify the defect, inadequate preparation of the defect area before positioning the graft, spontaneous CSF leak, elevated body mass index, location of leak in lateral sphenoid, and a massive skull base defect. ,,
|Table 2: Comparison with studies (with atleast 50 endoscopically treated patients) from literature|
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Spontaneous CSF leaks have the highest recurrence rate following surgical repair (25-87%), compared with <10% for most other etiologies. ,,,,,,,,,,,,,,, In a retrospective analysis of 72 patients over a 10-year period, Mirza et al., observed that 13 of 29 patients with spontaneous CSF leaks (46%) had evidence of raised intracranial pressure; 6 of the 13 patients with raised intracranial pressure (46%) had a recurrence of leak.  Chaaban et al., on the basis of their 5-year prospective study on 46 patients with 56 spontaneous CSF leaks, concluded that successful treatment of elevated intracranial pressure in combination with endoscopic repair can provide high success rates (93% primary and 100% secondary) approaching that of other etiologies.  In our series of 11 patients with spontaneous CSF leaks, 4 patients had evidence of raised intracranial pressure and underwent a lumbar thecoperitoneal shunt placement. Of the two failures, one patient had an anteromedial sphenoid encephalocele, whereas the other developed CSF leak at a site different from the primary repair site following lumbar thecoperitoneal shunt malfunction. Both patients underwent successful repair of CSF leak following a second endoscopic procedure along with revision of the thecoperitoneal shunt in the latter patient. To facilitate better visualization of the sphenoid recess during repeat surgical repair on patient with sphenoid encephalocele, an uncinotomy was performed along with anterior and posterior ethmoidectomy followed by widening of the sphenoid ostium. Gliotic tissue seen in the sphenoid sinus was shrunk with application of bipolar cautery. Mucosa of the sinus was removed, and the free graft was layered to check the dimensions and orientation for best fit. The remaining part of the repair was carried out as described for sphenoidal leaks.
There were five other patients (three posttraumatic and two postprocedural) in our series, which developed recurrence of leak following the initial endoscopic procedure. Poor graft uptake because of radiation therapy is the likely explanation for failure in the postprocedural group. One patient in the posttraumatic group had recurrence from a different anterior cranial fossa defect (possibly because of poor healing of skull base fracture) 17 months after the initial surgery. Technical reasons could be cited as the explanation for recurrence of leak in the remaining two patients, as they occurred at the same site within 10 days of the first procedure. Unlike other series, which have relied on the use of intraoperative fluorescein dye for localization of site of leak in cases, we relied only on correlation between surgical anatomy and imaging findings. This could have resulted in the two technical failures in our series.
Multiple successful techniques for repair of complex skull base defects, ranging from simple endoscopic local mucosal flaps to complex free tissue transfer with microvascular anastomosis, have been described in literature. , Hadad-Bassagasteguy flap has been recommended for reconstruction of large dural defects and in cases where postoperative radiation therapy is anticipated. , Alternatives include the transpterygoidtemporoparietal fascia flap and the posterior pedicle inferior turbinate flap. ,,
In a review of long-term outcomes of endoscopic repair, Zuckerman et al., focused on the timing of recurrent CSF leaks. The average time for recurrence in their series was 7 months (1-25 months).  Banks et al., observed spontaneous leaks recurring at 7 months (median range: 4 days-24 months) and traumatic leaks recurring at 4 months (median range: 4 days-29 months).  The authors also noted that 50% of traumatic recurrent leaks presented within the first 2 weeks of the postoperative period, probably reflecting a technical failure rather than a true recurrence. In our series, recurrence was observed within 10 days of the first endoscopic repair in two patients with posttraumatic CSF leak and one patient each in the spontaneous and postprocedural leaks. The remaining leaks occurred at 5, 17, and 23 months after the first procedure in the postprocedural, posttraumatic, and spontaneous CSF leak repairs, respectively.
In conclusion, team work between neurosurgeons and otorhinolaryngologists with attention to identification of sites of leak, surveillance for raised CSF pressure, preparation of graft bed, securing the graft in place, and postoperative care is critical to achieve a high success rate for endoscopic repair of CSF leaks. Lumbar drain may be placed following surgery in patients with recurrent leaks, posttraumatic leaks, leaks associated with large defect (>15 mm) or a meningoencephalocele. Patients with CSF leak caused by sphenoid encephaloceles are at increased risk of recurrence and should be counseled appropriately while obtaining informed consent.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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