Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage Using Multilayer Acellular Dermis

Ahmed Soliman Ismail; Peter D. Costantino; Chandranath Sen

doi:10.1055/s-2007-970556

Skull Base, Table of Contents

Skull Base 2007; 17(2): 125-131
DOI: 10.1055/s-2007-970556

ORIGINAL ARTICLE

Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage Using Multilayer Acellular Dermis

Ahmed Soliman Ismail¹ ^, ² , Peter D. Costantino¹ ^, ³ ^, ⁴ , Chandranath Sen¹ ^, ⁵

¹The Center for Cranial Base Surgery, St. Luke's Roosevelt Medical Center, New York, New York
²Faculty of Medicine, University of Alexandria, Alexandria, Egypt
³Department of Otolaryngology-Head and Neck Surgery, St. Luke's Roosevelt Medical Center, New York, New York
⁴Department of Clinical Otolaryngology, Columbia College of Physicians and Surgeons, New York, New York
⁵Department of Neurosurgery, St. Luke's Roosevelt Medical Center, New York, New York

Abstract

ABSTRACT

Cerebrospinal fluid (CSF) leaks result from a communication between the subarachnoid space and the upper aerodigestive tract. Because of the risk of complications such as meningitis, brain abscess, and pneumocephalus, all persistent CSF leaks should be repaired. Surgical repair may be achieved transcranially or extracranially using a wide variety of autogenous, allogenic, and synthetic patching materials. We report our results with a transnasal transsphenoidal endoscopic approach for the repair of CSF leaks coupled with a multilayer closure using acellular dermis (Alloderm™). We conducted a retrospective review of all patients presenting to our institution over the past 5 years with isolated sphenoid sinus CSF fistulas. Results: Twenty-one patients were included in the study. Nineteen patients (90.5%) had their sphenoid sinus CSF fistula repaired during the first attempt; 2 patients (9.5%) needed a second attempt. The multilayer repair of the CSF leak using acellular dermis via a transsphenoidal endoscopic approach is an effective and successful method of surgical repair of the fistula site. Neither the number, size, nor cause of the CSF fistula affected surgical outcomes. However, the presence of hydrocephalus was a significant negative variable, altering the surgical outcomes of our patients. The acellular dermis offers the advantage of not requiring autogenous tissue for the effective repair of CSF leaks in the sphenoid sinus.

KEYWORDS

Transnasal approach - multilayer repair - sphenoid sinus - CSF leak

Full Text

References

REFERENCES

1 Stankiewicz J A. Cerebrospinal fluid fistula and endoscopic sinus surgery. Laryngoscope. 1991; 101 250-256
2 Church C A, Chiu A G, Vaughan W C. Endoscopic repair of large skull base defects after powered sinus surgery. Otolaryngol Head Neck Surg. 2003; 129 204-209
3 Johnson D B, Brennan P, Toland J, O'Dwyer A J. Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistulae. Clin Radiol. 1996; 51 837-841
4 Shetty P G, Shroff M M, Fatterpekar G M, Sahani D V, Kirtane M V. A retrospective analysis of spontaneous sphenoid sinus fistula: MR and CT findings. AJNR Am J Neuroradiol. 2000; 21 337-342
5 El Gammal T, Sobol W, Wadlington V R et al.. Cerebrospinal fluid fistula: detection with MR cisternography. AJNR Am J Neuroradiol. 1998; 19 627-631
6 Gupta V, Goyal M, Mishra N K, Sharma A, Gaikwad S B. Positional MRI: a technique for confirming the site of leakage in cerebrospinal fluid rhinorrhoea. Neuroradiology. 1997; 39 818-820
7 Eljamel M S, Pidgeon C N, Toland J, Phillips J B, O'Dwyer A A. MRI cisternography, and the localization of CSF fistulae. Br J Neurosurg. 1994; 8 433-437
8 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
9 Meurman O H, Irjala K, Suonpaa J, Laurent B. A new method for the identification of cerebrospinal fluid leakage. Acta Otolaryngol. 1979; 87 366-369
10 McMains K C, Gross C W, Kountakis S E. Endoscopic management of cerebrospinal fluid rhinorrhea. Laryngoscope. 2004; 114 1833-1837
11 Arrer E, Meco C, Oberascher G, Piotrowski W, Albegger K, Patsch W. beta-Trace protein as a marker for cerebrospinal fluid rhinorrhea. Clin Chem. 2002; 48 939-941
12 Lanza D C, O'Brien D A, Kennedy D W. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope. 1996; 106 1119-1125
13 Hughes R G, Jones N S, Robertson I J. The endoscopic treatment of cerebrospinal fluid rhinorrhoea: the Nottingham experience. J Laryngol Otol. 1997; 111 125-128
14 Park J I, Strelzow V V, Friedman W H. Current management of cerebrospinal fluid rhinorrhea. Laryngoscope. 1983; 93 1294-1300
15 Zweig J L, Carrau R L, Celin S E et al.. Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success. Otolaryngol Head Neck Surg. 2000; 123 195-201
16 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. Otolaryngol Head Neck Surg. 1994; 111 600-605
17 Mattox D E, Kennedy D W. Endoscopic management of cerebrospinal fluid leaks and cephaloceles. Laryngoscope. 1990; 100 857-862
18 Casiano R R, Jassir D. Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?. Otolaryngol Head Neck Surg. 1999; 121 745-750
19 Mao V H, Keane W M, Atkins J P et al.. Endoscopic repair of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg. 2000; 122 56-60
20 Wax M K, Ramadan H H, Ortiz O, Wetmore S J. Contemporary management of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg. 1997; 116 442-449
21 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
22 Hegazy H M, Carrau R L, Snyderman C H, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope. 2000; 110 1166-1172
23 Wigand M E. Transnasal ethmoidectomy under endoscopical control. Rhinology. 1981; 19 7-15
24 Schick B, Ibing R, Brors D, Draf W. Long-term study of endonasal duraplasty and review of the literature. Ann Otol Rhinol Laryngol. 2001; 110 142-147
25 Wormald P J, McDonogh M. “Bath-plug” technique for the endoscopic management of cerebrospinal fluid leaks. J Laryngol Otol. 1997; 111 1042-1046
26 Gjuric M, Goede U, Keimer H, Wigand M E. Endonasal endoscopic closure of cerebrospinal fluid fistulas at the anterior cranial base. Ann Otol Rhinol Laryngol. 1996; 105 620-623
27 Kirtane M V, Gautham K, Upadhyaya S R. Endoscopic CSF rhinorrhea closure: our experience in 267 cases. Otolaryngol Head Neck Surg. 2005; 132 208-212
28 Costantino P D, Hiltzik D H, Sen C et al.. Sphenoethmoid cerebrospinal fluid leak repair with hydroxyapatite cement. Arch Otolaryngol Head Neck Surg. 2001; 127 588-593
29 Catalano P J, Post K, Sen C, Costantino P, Friedman C. Prevention of cerebrospinal fluid rhinorrhea in neurotologic surgery. Am J Otol. 2000; 21 265-269

Ahmed Soliman IsmailM.D. Ph.D.

The Center for Cranial Base Surgery, St. Luke's Roosevelt Medical Center

1000 Tenth Ave., Ste. 5G-80, New York, NY, 10019

Email: ahmedsoliman3@hotmail.com