Subcranial Transnasal Repair of Cerebrospinal Fluid Rhinorrhea with Free Autologous Grafts by the Combined Overlay and Underlay Techniques

Abstract

Objective: To determine the efficacy of subcranial transnasal repair of cerebrospinal fluid rhinorrhea with free autologous grafts by the combined overlay and underlay techniques using the surgical microscope and/or endoscope.

Patients and Methods: Twenty patients with CSF rhinorrhea were included in this retrospective study. They were 13 males and 7 females. Their age ranged from 7 to 62 years (mean: 39.35). The etiologies of the leak were iatrogenic in 10 cases, spontaneous in 5 cases, traumatic in 4 cases and one case was associated with meningeo-encephalocele. Preoperative nasal endoscopic examination, computed tomography (CT) with intrathecal non-ionic contrast and magnetic resonance imaging (MRI) were done when indicated. Endoscopic and/or microscopic repair of the CSF fistula was done by a combination of both underlay and overlay repair with free autologous grafts as follows: Gelfoam with fibrin glue, strips of fat, facia lata, Gelfoam with fibrin glue (underlay), septal cartilage, Gelfoam with fibrin glue and strips of fat (overlay).

Results: Complete closure of the leak was achieved in all patients. In one case of spontaneous CSF leak which was operated endoscopically, the leak recurred 6 months postoperatively and ceased spontaneously after a month with conservative medical treatment. No major complications were seen and no patients developed meningitis or postoperative anosmia.

Conclusion: Subcranial transnasal repair with free autologous grafts by the combined overlay and underlay techniques using the endoscope or surgical microscope is a safe and successful method of treating CSF leaks, provided that the CSF leak is precisely located and the site can be reached with the endoscope or surgical microscope.

Key words

Cerebrospinal fluid rhinorrhea - subcranial - transnasal - endoscopic - microscopic

References

• 1 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
• 2 Nachtigal D, Frenkiel S, Yoskovitch A, Mohr G. Endoscopic repair of cerebrospinal fluid rhinorrhea: is it the treatment of choice?.  J Otolaryngol. 1999;  28 129-133
• 3 Costa H, Cerejo A, Baptista A, Vaz R, Goncalves M, Guimaraes A, Amarante J, Cruz C, Guimaraes F. The galea frontalis myofascial flap in anterior fossa CSF leaks.  Br J Plast Surg. 1993;  46 503-507
• 4 Park J I, Strelzow V V, Friedman W H. Current management of cerebrospinal fluid rhinorrhea.  Laryngoscope. 1983;  93 1294-1300
• 5 Wigand W E. Transnasal ethmoidectomy under endoscopic control.  Rhinology. 1981;  19 7-15
• 6 Stankiewicz J A. Cerebrospinal fluid fistula and endoscopic sinus surgery.  Laryngoscope. 1991;  101 250-256
• 7 Lanza D C, O'Brien D A, Kennedy D W. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles.  Laryngoscope. 1996;  106 1119-1125
• 8 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
• 9 Abbeele T van den, Elmaleh M, Herman P, Francois M, Narcy P. Transnasal endoscopic repair of congenital defects of the skull base in children.  Arch Otolaryngol Head Neck Surg. 1999;  125 580-584
• 10 Andrews J C, Fisch U, Valavanis A, Aeppli U, Makek M S. The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach.  Laryngoscope. 1989;  99 429-437
• 11 Mattox D E, Kennedy D W. Endoscopic management of cerebrospinal fluid leaks and cephaloceles.  Laryngoscope. 1990;  100 857-862
• 12 Stechison M T. Rapid polymerizing fibrin glue from autologous or single donor blood: Preparation and indications.  J Neurosurg. 1992;  76 626-628
• 13 Applebaum E L, Chow J M. Otolaryngology Head and Neck Surgery (volume 2-A), 3^rd edition. Cummings CW, Fredrickson JM, Harker LA and others (editors). London: Mosby 1999
• 14 Daly D T, Lydiatt W M, Ogren F P, Moore G F. Extracranial approaches to the repair of cerebrospinal fluid rhinorrhea.  Ear Nose Throat J. 1992;  71 311-313
• 15 Papay F A, Maggiano H, Dominquez S, Hassenbusch S J, Levine H L, Lavertu P. Rigid endoscopic repair of paranasal sinus cerebrospinal fluid fistulas.  Laryngoscope. 1989;  99 1195-1201
• 16 Wormald P J, McDonogh M. “Bath-plug” technique for the endoscopic management of cerebrospinal fluid leaks.  J Laryngol Otol. 1997;  111 1042-1046
• 17 Weber R, Keerl R, Draf W, Schick B, Mosler P, Saha A. Management of dural lesions occurring during endonasal sinus surgery.  Arch Otolaryngol Head Neck Surg. 1996;  122 732-736
• 18 Velthoven V van, Clarici G, Auer L M. Fibrin tissue adhesive sealant for the prevention of CSF leakage following transsphenoidal microsurgery.  Acta Neurochir (Wien). 1991;  109 26-29
• 19 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. 199;  111 600-605