RSS-Feed abonnieren
DOI: 10.1055/s-2005-870904
Transnasal Endoscopic Repair of Cerebrospinal Fluid Fistulas and Encephaloceles: Surgical Indications and Complications
Publikationsverlauf
Publikationsdatum:
13. Juli 2005 (online)
![](https://www.thieme-connect.de/media/min/200503/lookinside/thumbnails/10.1055-s-2005-870904-1.jpg)
Abstract
Introduction: Transnasal endoscopic repair of cerebrospinal fluid (CSF) fistulas is recommended for patients with CSF leaks who do not respond to conservative treatment. It is a safer and more successful alternative to transcranial surgery. Patients and Methods: We present our experience on using transnasal endoscopy for the repair of anterior skull base cerebrospinal fluid fistulas. Between 1999 and 2003 we observed 20 patients with CSF rhinorrhea. The etiology was heterogeneous: post-traumatic in 6 cases, iatrogenic in 6 cases (one interesting case of meningioma of the sphenoethmoid plate), dysembryogenetic - due to encephaloceles - in 4 patients (one with Cruzon syndrome and one with Down syndrome) and idiopathic in the other 4 patients. Use of a rigid transnasal endoscope allowed the localization and repair of all fistulas, with the use of fluorescein in 6 cases. Different grafts were used, in particular fat, bone or chondral septum with mucoperiosteum or perichondral mucosa. Generally the graft was inserted with the underlay or the sandwich technique. Lumbar drainage was used in the postoperative period only in 6 cases. No antibiotic prophylactic therapy was used. Results: Endoscopy was successful in 90 % of patients at the first attempt, and in 95 % of patients at the second approach. We had two late complications such as infections. In one child with a post-traumatic fistula and shunt for hydrocephalus, we observed meningitis 2 years after the first endoscopic surgery and he underwent both transnasal endoscopic surgery and transcranial surgery. The second patient was a woman with a spontaneous fistula, who had rhinoliquorrhea three years after the first surgical treatment. During surgery a strange similar purulent material filling the submucous space of the ethmoid roof was found, suggestive for an intranasal abscess that was removed. We did not see any complications such as hematomas or seizures. The follow-up (range: 6 months to 3 years) made both with MRI and rhinoscopy has not shown any relapse until now in 19 of 20 patients treated only with endoscopy. Conclusions: The endoscopic approach is highly effective and safe in the treatment of CSF fistulas, with great visualization and minimal invasiveness, for which it is associated to a very low morbidity. The fluorescein technique is extremely helpful for the diagnosis and surgery of CSF leaks.
Key words
Cerebrospinal fistula - transsphenoidal endoscopy - encephalocele
References
- 1 Nandapalan V, Watson I D, Swift A C. Beta 2 transferrin and cerebrospinal fluid rhinorrhea. Clin Otolarygol. 1996; 21 259-264
- 2 Eljamel M S, Foy P M. Post traumatic CSF fistulae, the case for surgical repair. Br J Neurosurg. 1990; 4 479-483
- 3 Aarabi B, Leibrock L G. Neurosurgical approaches to cerebrospinal fluid rhinorrhea. Ear Nose Throat J. 1992; 71 300-305
- 4 Bibas A G, Skia B, Hickey S A. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea. Br J Neurosurg. 2000; 14 49-52
- 5 Hubbard J L, McDonald T C, Pearson B W. Spontaneous cerebrospinal fluid rhinorrhea: evolving concepts in diagnosis and management based on the Mayo Clinic experience from 1970 to 1981. Neurosurgery. 1985; 16 314-321
- 6 Park J I, Strelzow V V, Friedman W H. Current management of cerebrospinal fluid rhinorrhea. Laryngoscope. 1983; 93 1294-1300
- 7 Bartley J. Extracranial repair of cerebrospinal fluid rhinorrhoea. Aust NZ Surg. 1998; 68 359-362
- 8 Dohlman G. Spontaneous cerebrospinal rhinorrhea. Acta Otolaryngol Suppl (Stockh). 1948; 67 20-23
- 9 Hirsch O. Successful closure of cerebrospinal fluid rhinorrhea by endonasal surgery. Arch Otolaryngol. 1952; 56 1-13
- 10 Vrabec D P, Hallberg O E. Cerebrospinal fluid rhinorrhea. Arch Otolaryngol. 1964; 80 218-229
- 11 Mattox D E, Kennedy D W. Endoscopic management of cerebrospinal fluid leaks and encephaloceles. Laryngoscope. 1990; 100 857-862
- 12 Wigand W E. Transnasal ethmoidectomy under endoscopic control. Rhinology. 1981; 19 7-15
- 13 Calcaterra T C. Extracranial surgical repair of cerebrospinal fluid rhinorrhea. Ann Otol Rhinol Laryngol. 1980; 89 108-116
- 14 Dodson E E, Gross C W, Swerdloff J L, Gustafson L M. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. Otol Head Neck Surg. 1994; 111 600-605
- 15 Persky M S, Rothstein S G, Breda S D. Extracranial repair of cerebrospinal fluid otorhinorrhea. Laryngoscope. 1991; 101 134-136
- 16 Burns J A, Dodson E E, Gross C W. Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up. Laryngoscope. 1996; 106 1080-1083
- 17 Lanza D C, O'Brien D A, Kennedy D W. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope. 1996; 106 1119-1125
- 18 Mao V H, Keane W M, Atkins J P. Endoscopic repair of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg. 2000; 122 56-60
- 19 Schick B, Brors D, Ibing R, Draf W. Long term study of endonasal duraplasty and review of the literature. Ann Otol Rhinol Laryngol. 2001; 110 142-147
- 20 Zweig J L, Carrau R L, Celin S E. Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success. Otolaryngol Head Neck Surg. 2000; 123 195-201
- 21 Gupta V, Goyal M, Mishra N. MR evaluation of CSF fistulae. Acta Radiol. 1997; 38 603-609
- 22 Johnson D BS, Toland B J, O'Dwyer A J. Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistulae. Clin Radiol. 1996; 51 837-841
- 23 Zapalac J S, Marple B F, Schwade N D. Skull base cerebrospinal fluid fistulas: A comprehensive diagnostic algorithm. Otolaryngol Head Neck Surg. 2002; 126 669-676
- 24 Shetty P G, Shroff M M, Sahani D V. Evaluation of high resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula. Am J Neuroradiol. 1998; 19 633-639
- 25 Reilly P, Krishnan S. Cerebrospinal fluid fistula. In: Kaye AH, Black PMcL (Eds), Operative Neurosurgery. London, Churchill Livingstone 2000: 265-277
- 26 Spetzler R F, Zabramski J M. Cerebrospinal fluid fistula. Contemp Neurosurg. 1986; 8 1-7
- 27 Mehendale N H, Marple B F, Nussenbaum B. Management of sphenoid sinus cerebrospinal fluid rhinorrhea: Making use of an extended approach to the sphenoid sinus. Otolaryngol Head Neck Surg. 2002; 126 147-153
- 28 Roland P S, Marple B F, Meyerhoff W L. Complications of lumbar spinal fluid drainage. Otolaryngol Head Neck Surg. 1992; 107 564-569
- 29 Zeitouni A G, Freinkeil S, Mohr G. Endoscopic repair of anterior skull base CSF fistulas: An emphasis on postoperative function maximisation. J Otolaryngol. 1994; 23 225-227
- 30 Hughes R GM, Jones N S, Robertson I JA. The endoscopic treatment of cerebrospinal fluid rhinorrhoea: the Nottingham experience. J Laryngol Otol. 1997; 111 125-128
- 31 Herman P, Lot G, Guichard J P. Mucocele of the sphenoid sinus: a late complication of transsphenoidal pituitary surgery. Ann Otol Rhinol Laryngol. 1998; 107 765-768
Dr. Elisabetta Marton
Neurosurgical Department · Regional Hospital
Piazzale Ospedale
31100 Treviso
Italy
Telefon: +39-0422-322-576
Fax: +39-0422-322-523
eMail: emarton@ulss.tv.it