Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

Zi Yang Jiang; Caitlin McLean; Carlos Perez; Samuel Barnett; Deborah Friedman; Bobby A. Tajudeen; Pete S. Batra

doi:10.1055/s-0037-1606306

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2018; 79(02): 193-199
DOI: 10.1055/s-0037-1606306

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

Zi Yang Jiang

¹Department of Otolaryngology – Head and Neck Surgery, University of Texas Health Science Center in Houston, Houston, Texas, United States

,

Caitlin McLean

²Department of Otolaryngology – Head and Neck Surgery, Temple University, Philadelphia, Pennsylvania, United States

,

Carlos Perez

³Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States

,

Samuel Barnett

⁴Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States

,

Deborah Friedman

⁵Departments of Neurology & Neurotherapeutics and Ophthalmology, University of Texas Southwestern Medical Center Dallas, Texas, United States

,

Bobby A. Tajudeen

⁶Department of Otorhinolaryngology – Head and Neck Surgery and Center for Skull Base and Pituitary Surgery, Rush University Medical Center, Chicago, Illinois, United States

,

Pete S. Batra

⁶Department of Otorhinolaryngology – Head and Neck Surgery and Center for Skull Base and Pituitary Surgery, Rush University Medical Center, Chicago, Illinois, United States

› Author Affiliations

Abstract

Background The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable.

Methods Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed.

Results Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture (n = 32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema.

Conclusions Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.

Keywords

endoscopy - cerebrospinal fluid - leak - rhinorrhea - spontaneous - skull base - intracranial hypertension

Full Text

References

References
1 Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2015; (04) CD004884
2 Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic endonasal versus open repair of anterior skull base CSF leak, meningocele, and encephalocele: a systematic review of outcomes. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (04) 239-250
3 Ambika S, Arjundas D, Noronha V. , Anshuman. Clinical profile, evaluation, management and visual outcome of idiopathic intracranial hypertension in a neuro-ophthalmology clinic of a tertiary referral ophthalmic center in India. Ann Indian Acad Neurol 2010; 13 (01) 37-41
4 Schlosser RJ, Wilensky EM, Grady MS, Bolger WE. Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks. Am J Rhinol 2003; 17 (04) 191-195
5 Schlosser RJ, Woodworth BA, Wilensky EM, Grady MS, Bolger WE. Spontaneous cerebrospinal fluid leaks: a variant of benign intracranial hypertension. Ann Otol Rhinol Laryngol 2006; 115 (07) 495-500
6 Chaaban MR, Illing E, Riley KO, Woodworth BA. Spontaneous cerebrospinal fluid leak repair: a five-year prospective evaluation. Laryngoscope 2014; 124 (01) 70-75
7 Allen KP, Perez CL, Kutz JW, Gerecci D, Roland PS, Isaacson B. Elevated intracranial pressure in patients with spontaneous cerebrospinal fluid otorrhea. Laryngoscope 2014; 124 (01) 251-254
8 Brainard L, Chen DA, Aziz KM, Hillman TA. Association of benign intracranial hypertension and spontaneous encephalocele with cerebrospinal fluid leak. Otol Neurotol 2012; 33 (09) 1621-1624
9 Chaaban MR, Illing E, Riley KO, Woodworth BA. Acetazolamide for high intracranial pressure cerebrospinal fluid leaks. Int Forum Allergy Rhinol 2013; 3 (09) 718-721
10 Stangherlin P, Ledeghen S, Scordidis V, Rubay R. Benign intracranial hypertension with recurrent spontaneous cerebrospinal fluid rhinorrhoea treated by laparoscopic gastric banding. Acta Chir Belg 2008; 108 (05) 616-618
11 Lueck C, McIlwaine G. Interventions for idiopathic intracranial hypertension. Cochrane Database Syst Rev 2002; (03) CD003434
12 Degnan AJ, Levy LM. Pseudotumor cerebri: brief review of clinical syndrome and imaging findings. AJNR Am J Neuroradiol 2011; 32 (11) 1986-1993
13 Kutz Jr JW, Husain IA, Isaacson B, Roland PS. Management of spontaneous cerebrospinal fluid otorrhea. Laryngoscope 2008; 118 (12) 2195-2199
14 Nelson RF, Gantz BJ, Hansen MR. The rising incidence of spontaneous cerebrospinal fluid leaks in the United States and the association with obesity and obstructive sleep apnea. Otol Neurotol 2015; 36 (03) 476-480
15 Rosenfeld E, Dotan G, Kimchi TJ, Kesler A. Spontaneous cerebrospinal fluid otorrhea and rhinorrhea in idiopathic intracranial hypertension patients. J Neuroophthalmol 2013; 33 (02) 113-116
16 Stevens SM, Rizk HG, Golnik K. , et al. Idiopathic intracranial hypertension: Contemporary review and implications for the otolaryngologist. Laryngoscope 2017;
17 Prichard CN, Isaacson B, Oghalai JS, Coker NJ, Vrabec JT. Adult spontaneous CSF otorrhea: correlation with radiographic empty sella. Otolaryngol Head Neck Surg 2006; 134 (05) 767-771
18 Banks CA, Palmer JN, Chiu AG, O'Malley Jr BW, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg 2009; 140 (06) 826-833
19 Martínez-Capoccioni G, Serramito-García R, Martín-Bailón M, García-Allut A, Martín-Martín C. Spontaneous cerebrospinal fluid leaks in the anterior skull base secondary to idiopathic intracranial hypertension. Eur Arch Otorhinolaryngol 2017; 274 (05) 2175-2181
20 Woodworth BA, Schlosser RJ, Palmer JN. Endoscopic repair of frontal sinus cerebrospinal fluid leaks. J Laryngol Otol 2005; 119 (09) 709-713
21 Pérez MA, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol 2013; 33 (04) 330-337
22 Ten Hove MW, Friedman DI, Patel AD, Irrcher I, Wall M, McDermott MP. ; NORDIC Idiopathic Intracranial Hypertension Study Group. Safety and tolerability of acetazolamide in the idiopathic intracranial hypertension treatment trial. J Neuroophthalmol 2016; 36 (01) 13-19
23 Piper RJ, Kalyvas AV, Young AM, Hughes MA, Jamjoom AA, Fouyas IP. Interventions for idiopathic intracranial hypertension. Cochrane Database Syst Rev 2015; (08) CD003434
24 Radhakrishnan K, Ahlskog JE, Cross SA, Kurland LT, O'Fallon WM. Idiopathic intracranial hypertension (pseudotumor cerebri). Descriptive epidemiology in Rochester, Minn, 1976 to 1990. Arch Neurol 1993; 50 (01) 78-80
25 Durcan FJ, Corbett JJ, Wall M. The incidence of pseudotumor cerebri. Population studies in Iowa and Louisiana. Arch Neurol 1988; 45 (08) 875-877
26 Dallas/Fort-Worth Census data. https://www.dshs.texas.gov/chs/popdat/ST2013.shtm . Accessed April 4, 2017
27 Bakhsheshian J, Hwang MS, Friedman M. Association between obstructive sleep apnea and spontaneous cerebrospinal fluid leaks: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg 2015; 141 (08) 733-738
28 Jennum P, Børgesen SE. Intracranial pressure and obstructive sleep apnea. Chest 1989; 95 (02) 279-283
29 Stadelmann K, Latshang TD, Nussbaumer-Ochsner Y. , et al. Impact of acetazolamide and CPAP on cortical activity in obstructive sleep apnea patients. PLoS One 2014; 9 (04) e93931
30 Kattah JC, Pula JH, Mejico LJ, McDermott MP, Kupersmith MJ, Wall M. CSF pressure, papilledema grade, and response to acetazolamide in the Idiopathic Intracranial Hypertension Treatment Trial. J Neurol 2015; 262 (10) 2271-2274
31 Aaron G, Doyle J, Vaphiades MS, Riley KO, Woodworth BA. Increased intracranial pressure in spontaneous CSF leak patients is not associated with papilledema. Otolaryngol Head Neck Surg 2014; 151 (06) 1061-1066