Endoscopic Repair of CSF Rhinorrhea
Michael Briscoe Jr MD Faculty Advisor Matthew Ryan MD
Department of Otolaryngology The University of Texas Medical Branch at Galveston
Grand Rounds Presentation November 15 2006
Overview
bull History
bull CSF physiology
bull Pertinent HPI and PE
bull Diagnostic Testing
bull Classification
bull Treatment
bull Conclusion
History
bull First repair of CSF leak by Dandy in 1926 using frontal craniotomy (60-80 success rate)
bull 1948 first extracranial approach by Dohlman (Naso-orbital incision)
bull 1952 Hirsch performed transnasal approach
bull First endoscopic CSF rhinorrhea repair in 1981 by Wigand (~90 or better success rate)
ndash Less morbidity
ndash Standard of care for most cases of CSF rhinorrhea
Cerebrospinal Fluid
bull CSF functions to give physical support and protection to the brain transport waste products and to regulate the chemical environment of the brain
CSF Physiology
bull Total Volume of CSF in adult is 90-150 ml
bull CSF is made in the choroid plexus and ependyma at rate of 35 mlmin (500 mld)
bull Absorbed in arachnoid villi total volume turned over 3-5 times per day
Flow rate of CSF
bull Flow rates of CSF can be measured using MRI
Flow of CSF
bull Flows from Lateral ventricle through foramen of Monroe to 3rd ventricle
bull Then through aqueduct of sylvius to 4th ventricle
bull Next flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Overview
bull History
bull CSF physiology
bull Pertinent HPI and PE
bull Diagnostic Testing
bull Classification
bull Treatment
bull Conclusion
History
bull First repair of CSF leak by Dandy in 1926 using frontal craniotomy (60-80 success rate)
bull 1948 first extracranial approach by Dohlman (Naso-orbital incision)
bull 1952 Hirsch performed transnasal approach
bull First endoscopic CSF rhinorrhea repair in 1981 by Wigand (~90 or better success rate)
ndash Less morbidity
ndash Standard of care for most cases of CSF rhinorrhea
Cerebrospinal Fluid
bull CSF functions to give physical support and protection to the brain transport waste products and to regulate the chemical environment of the brain
CSF Physiology
bull Total Volume of CSF in adult is 90-150 ml
bull CSF is made in the choroid plexus and ependyma at rate of 35 mlmin (500 mld)
bull Absorbed in arachnoid villi total volume turned over 3-5 times per day
Flow rate of CSF
bull Flow rates of CSF can be measured using MRI
Flow of CSF
bull Flows from Lateral ventricle through foramen of Monroe to 3rd ventricle
bull Then through aqueduct of sylvius to 4th ventricle
bull Next flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
History
bull First repair of CSF leak by Dandy in 1926 using frontal craniotomy (60-80 success rate)
bull 1948 first extracranial approach by Dohlman (Naso-orbital incision)
bull 1952 Hirsch performed transnasal approach
bull First endoscopic CSF rhinorrhea repair in 1981 by Wigand (~90 or better success rate)
ndash Less morbidity
ndash Standard of care for most cases of CSF rhinorrhea
Cerebrospinal Fluid
bull CSF functions to give physical support and protection to the brain transport waste products and to regulate the chemical environment of the brain
CSF Physiology
bull Total Volume of CSF in adult is 90-150 ml
bull CSF is made in the choroid plexus and ependyma at rate of 35 mlmin (500 mld)
bull Absorbed in arachnoid villi total volume turned over 3-5 times per day
Flow rate of CSF
bull Flow rates of CSF can be measured using MRI
Flow of CSF
bull Flows from Lateral ventricle through foramen of Monroe to 3rd ventricle
bull Then through aqueduct of sylvius to 4th ventricle
bull Next flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Cerebrospinal Fluid
bull CSF functions to give physical support and protection to the brain transport waste products and to regulate the chemical environment of the brain
CSF Physiology
bull Total Volume of CSF in adult is 90-150 ml
bull CSF is made in the choroid plexus and ependyma at rate of 35 mlmin (500 mld)
bull Absorbed in arachnoid villi total volume turned over 3-5 times per day
Flow rate of CSF
bull Flow rates of CSF can be measured using MRI
Flow of CSF
bull Flows from Lateral ventricle through foramen of Monroe to 3rd ventricle
bull Then through aqueduct of sylvius to 4th ventricle
bull Next flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
CSF Physiology
bull Total Volume of CSF in adult is 90-150 ml
bull CSF is made in the choroid plexus and ependyma at rate of 35 mlmin (500 mld)
bull Absorbed in arachnoid villi total volume turned over 3-5 times per day
Flow rate of CSF
bull Flow rates of CSF can be measured using MRI
Flow of CSF
bull Flows from Lateral ventricle through foramen of Monroe to 3rd ventricle
bull Then through aqueduct of sylvius to 4th ventricle
bull Next flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Flow rate of CSF
bull Flow rates of CSF can be measured using MRI
Flow of CSF
bull Flows from Lateral ventricle through foramen of Monroe to 3rd ventricle
bull Then through aqueduct of sylvius to 4th ventricle
bull Next flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Flow of CSF
bull Flows from Lateral ventricle through foramen of Monroe to 3rd ventricle
bull Then through aqueduct of sylvius to 4th ventricle
bull Next flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Intracranial Pressure
bull Normal ICP is 5 to 15 cm H2O while supine
bull Pressure changes with movement time of day cardiac cycle and respiratory phase
bull Raised during REM sleep sneezing laughing and Valsalva
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Disease processes involving CSF
bull Hydrocephalus
bull Meningitis
bull CSF leak
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
CSF Leaks
bull Occur due to dural tears or areas of dural weakness
ndash Otorrhea due to temporal bone fractures
ndash Rhinorrhea due to anterior or central skull base dural defects
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Presenting Symptoms
bull Recurrent Meningitis
bull Intracranial abscess
bull Rhinorrhea unilateral or bilateral
bull Headache
bull Obstructing nasal mass
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
HPI
bull Duration of symptoms
bull Onset of symptoms
bull Associated symptoms
bull Severity of rhinorrhea
bull Laterality of symptoms
bull Quantity and quality of rhinorrhea
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Important Questions
bull Recent trauma
bull History of recurrent meningitis
bull Recent sinus surgery endoscopic surgery or neurosurgery
bull History of hydrocephalus or increased intracranial pressure
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Physical Exam
bull Complete otolaryngologic exam
bull Cranial nerve testing
bull Nasal endoscopy
bull Weight and BMI
bull Testing for meningeal irritation such as nuchal rigidity Kernigrsquos or Brudzinsky
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Findings
bull Clear rhinorrhea
bull Bony deformity
bull Intranasal mass
bull Meningeal signs
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Differential Diagnosis
bull Autonomic dysfunction
bull Atrophic Rhinitis
bull Allergic Rhinitis
bull Sinonasal Polyposis
bull Temporal bone fracture with otorrhea
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Laboratory Testing
bull CSF has a slightly different composition than serum
bull Some proteins are found predominantly in CSF
ndash Beta 2 transferrin
ndash Beta trace protein 2nd most abundant protein found in CSF
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Laboratory Testing
bull In active rhinorrhea fluid sample can be collected at initial evaluation
bull With intermittent rhinorrhea patient may collect sample at home
bull Need at least 05ml of fluid
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Beta 2 transferrin
bull Produced by neuraminidase activity in the brain and found only in csf perilymph and aqueous humor
bull Electrophoresis used to detect
bull Most used laboratory test 88 specif
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Beta trace protein
bull Synthesized in choroid plexus
bull Concentration in CSF ~35 fold higher than plasma
bull Quick screening test
bull Not useful in patients with renal insufficiency or bacterial meningitis
bull Sensitivity 78-100
bull Specificity 86-100
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Imaging
bull CT scan
bull MRI
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
CT Scan
bull CT scan is essential because of greater bone detail
bull Need high resolution scans 30mm or less cuts
bull Axial with coronal reformats
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
MRI
bull For congenital cases of CSF rhinorrhea
bull Can identify areas of meningocele or encephaloceles
bull Can identify areas were dura is thinned
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Additional Testing
bull Intrathecal fluorescein aided nasal endoscopy
bull Cisternography Metrizamide CT cisternography or MR-cisternography
bull States of low flow or areas of thinning of dura can be identified
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Intrathecal Fluorescein
bull 05 to 10 (25-50mg) fluorescein injected into lumbar space prior to examination
bull Mixed with 10 cc of CSF and slowly injected over 10-20 minutes
bull Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source
bull ldquoOff labelrdquo use
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
IT Fluorescein complications
bull Transient pulmonary edema
bull Seizure
bull Transient numbness in extremities
bull Death
bull Severe side effects seen with doses of gt 500mg
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Radioisotope Cisternography
bull Radioactive contrast into intrathecal space
bull Pledgets placed in ant cribriform middle meatus and sphenoethmoidal recesses
bull Left in place for several hours
bull Detects laterality of defect but not precise location
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Carrau et alCerebrospinal Fluid
Leaks Laryngoscope 115
Metrizamide CT Cistern
bull Intrathecal contrast injected
bull Great for sphenoid or frontal sinus leaks and assessing meningoencephalocele
bull Sensitivity 48-96
bull Complications include
ndash Headache
ndash Nausea
ndash arachnoiditis
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
MR Cisternography
bull No contrast material needed
bull Highlights CSF fistulas
bull Identifies brain parenchyma and CSF in meningoencephaloceles
bull 85-92 sensitivity and 57-100 specificity
bull Can detect intermittent or low flow leaks
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Classification of CSF Rhinorrhea
bull Etiology - most important factor for success of surgery
bull Location - most important factor for approach
bull Size of defect
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Etiology bull Traumatic ndash 10-30 of ant Skull base fractures have
associated rhinorrhea ndash Most common cause ndash Blunt vs penetrating
bull Congenital ndash encephalocele
bull Iatrogenic ndash Sinus surgery transphenoidal hypophysectomy other neuro
procedures
bull Tumor ndash Invasion through skull base
bull Spontaneous ndash Usually attributed to increased ICP
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Traumatic injury
bull Rhinorrhea usually presents within first 48 hours
bull 70 close with conservative intervention
bull Those not surgically closed assoc with 30-40 risk of ascending meningitis
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Iatrogenic
bull FESS
ndash Lateral lamella of cribriform plate
ndash Posterior ethmoid near the roof of the antero-medial wall of sphenoid
bull Skull base surgery
bull Transphenoidal hypophysectomy
ndash Disruption of sellar diaphragm
bull Craniofacial resections
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Congenital
bull Relatively rare
bull Present as meningoencephalocele
bull Congenital hydrocephalus
bull Congenital skull base defect
bull Usually have large funnel-shaped defects
bull Normal ICP
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Sites of Lesions
bull Cribriform plate
bull Ethmoid
bull Frontal
bull Sphenoid
bull Multiple
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Management
bull Conservative
bull Open
bull Endoscopic
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Conservative
bull Reserved for blunt trauma with resolving CSF rhinorrhea
bull May need lumbar drain
bull HOB elevated no nose blowing or valsalva
bull Acetazolamide to decrease CSF production when raised ICP is suspected
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Open Technique
bull Reserved for large defects multiple defects or defects to lateral sphenoid sinus
bull Posterior table of frontal sinus
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Endoscopic Technique
bull Most causes of CSF rhinorrhea can be managed this way
bull Varying techniques and graft material
bull gt90 first time success rate reported in literature
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Approaches to Anterior Cranium base
bull Paraseptal approach ndash cribriform plate eth
ndash with or without sphenoidotomy
bull Transethmoidal - sphenoid
ndash With or without removal of basal lamella
bull Transethmoidal-pterygoidal-sphenoidal
ndash Lateral recess of sphenoid
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Paraseptal approach
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Transethmoidal
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Locatelli etal Endoscopic
endonasal apporaches Operative
Neurosurgery
Transethmoidal-sphenoidal-pterygoidal
bull This type of approach was useful for defects located in the lateral wall of the sphenoid sinus After performing an ethmoido-sphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Transethmoidal-pterygoidal-sphenoidal
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Graft Material
bull Cartilage and mucoperichondrium
bull Middle turbinate
bull Conchal cartilage
bull Abdominal fat
bull Mucosa
bull Fascia
bull Combined
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Middle turbinate harvest
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Preparation of graft site
bull Recipient bed is prepared by removing several mm of mucosa to widely expose the defect
bull Mucosa must be thoroughly removed to increase adherence to site
bull Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Closure Techniques
bull Overlay
bull Combined
bull Obliteration
bull Gel foam packing
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Post-operative management
bull Bedrest
bull Stool softeners
bull +- lumbar drain
bull Avoid raising ICP
bull Repeat endoscopic evaluations
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Predictors of success
bull Good pre-operative work up
bull Technically proficient with sinus surgery
bull Adequate exposure of defect
bull Choosing optimal procedure based on location
bull Normal ICP
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Contraindications
bull Presence of intracranial lesions
bull Comminuted fractures of the cranium base
bull Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Complications
bull Meningitis (03)
bull Persistent leak (5-10)
bull Pneumocephalus
bull Intracranial hemorrhage or hematoma (03)
bull Frontal lobe abscess (09)
bull Anosmia (06)
bull Chronic headache (03)
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Conclusions
bull Nasal endoscopy
bull Beta-2-transferrin or beta trace protein
bull Imaging to localize defect HRCT for bony defects MRI for herniations
bull Endoscopy provides 90 1st time success and up to 97 after 2nd look
bull Patients require close follow-up for resolution of rhinorrhea
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
Resources bull Hegazy HM et al Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea a Meta-analysis
Laryngoscope 20001101166-1172 bull Schlosser RJ Bolger WE Nasal Cerebrospinal Fluid Leaks Critical Review and Surgical Considerations
Laryngoscope 2004114255-265 bull Locatelli D et al Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks Nine Year
Experience Operative Neurosurgery 200658246-57 bull Lidstrom DR et al Management of Cerebrospinal Fluid Rhinorrhea The Medical College of Wisconsin
Experience Laryngoscope 2004114969-974 bull Meco C Oberascher G Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid
Fistula Diagnosis Laryngoscope 2004114991-999 bull Mirza S et al Sinonasal Cerebrospinal Fluid Leaks Management of 97 Patients Over 10 Years
Laryngoscope 20051151774-1777 bull Keerl R et al Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas
Laryngoscope 2004114266-272 bull Carrau RL et al The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure
Hydrocephalus Laryngoscope 2005115205-212 bull Han CY Backous DD Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure
Homeostasis Otolaryngol Clin N Am 200538569-576 bull Meco C et al B-Trace protein test New guidelines for the reliable diagnosis of cerebrospinal fluid
fistula Otolaryngol Head Neck Surg 2003129508-517 bull Schnabel C et al Comparison of B2-transferrin and B-trace protein for detection of Cerebrospinal Fluid
in Nasal and Ear Fluids Clinical Chemistry 200450661-663 bull Zweig JL et al Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract Predictors of
success Otolaryngology-Head and Neck Surgey 2000123195-201 bull Schlosser RJ Bolger WE Endoscopic Management of Cerbrospinal Fluid Rhinorrhea Otolaryngol Clin N
Am 200639523-538 bull Chatrath P Saleh HA Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate
Laryngocope 20061161050-1053
