Endonasal Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: A Study of 263 Patients

Abstract

Background Cerebrospinal fluid (CSF) rhinorrhea is a sign of a breach in the bony skull base. It should be verified, localized, and repaired surgically to alleviate the risk of intracranial infection. Endonasal endoscopic surgery is the standard technique for skull base reconstruction in these patients. The current study was undertaken to evaluate a large case series of patients with CSF rhinorrhea who underwent surgery, focusing on symptoms, etiology, specifics of skull base defects, reconstruction techniques, outcomes, and complications.

Methods All patients with CSF rhinorrhea who were treated endoscopically for a skull base defect from 2010 to 2023 in a tertiary referral hospital were included.

Results In this retrospective study, 263 patients were included. The chief presenting symptom was rhinorrhea. Spontaneous CSF leak was the most common etiologic factor, whereas accidental trauma accounted for about one-third of the cases. In cases of spontaneous CSF rhinorrhea, the most common sites of skull base defects were the cribriform plate, lateral lamella of the ethmoid, and the lateral recess of the sphenoid. The frontal sinus was the most common site of defect in cases of accidental traumatic CSF rhinorrhea. In the majority of cases, a two-layer technique using inlay fat and onlay fascia was employed for skull base reconstruction. Recurrences, including technical failures, missed skull base defects, and late new skull base defects, were observed in 10 cases (3.8%). Three patients developed meningitis in the early postoperative period, but all recovered uneventfully.

Conclusion Given the high success rate and low morbidity, all patients with CSF rhinorrhea should be counseled to undergo endoscopic surgery early.

Keywords

endoscopic skull base reconstruction - CSF rhinorrhea - skull base defect - skull base reconstruction

Publication History

Received: 22 September 2024

Accepted: 16 December 2024

Article published online:
13 January 2025

• References

• 1 Banks CA, Palmer JN, Chiu AG, O'Malley Jr BW, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg 2009; 140 (06) 826-833
• 2 Stoker MA, Forbes JA, Hanif R. et al. Decreased rate of CSF leakage associated with complete reconstruction of suboccipital cranial defects. J Neurol Surg B Skull Base 2012; 73 (04) 281-286
• 3 Pelosi S, Bederson JB, Smouha EE. Cerebrospinal fluid leaks of temporal bone origin: selection of surgical approach. Skull Base 2010; 20 (04) 253-259
• 4 Leonetti JP, Marzo S, Anderson D, Origitano T, Vukas DD. Spontaneous transtemporal CSF leakage: a study of 51 cases. Ear Nose Throat J 2005; 84 (11) 700 , 702–704, 706
• 5 Ahilasamy N, Narendrakumar V, Rajendran DK, Sivaprakasam R. Cribriform CSF leak: endoscopic surgical repair using free septal mucosal graft without postoperative nasal packs. Indian J Otolaryngol Head Neck Surg 2021; 73 (03) 290-295
• 6 Bachert C, Verhaeghe B, van Cauwenberge P, Daele J. Endoscopic endonasal surgery (EES) in skull base repairs and CSF leakage. Acta Otorhinolaryngol Belg 2000; 54 (02) 179-189
• 7 Xie M, Zhou K, Kachra S, McHugh T, Sommer DD. Diagnosis and localization of cerebrospinal fluid rhinorrhea: a systematic review. Am J Rhinol Allergy 2022; 36 (03) 397-406
• 8 Dandy We. Treatment of rhinorrhea and otorrhea. Arch Surg 1944; 49: 75-85
• 9 Hosemann W, Goertzen W, Wohlleben R, Wolf S, Wigand ME. Olfaction after endoscopic endonasal ethmoidectomy. Am J Rhinol 1993; 7: 11-15
• 10 DeConde AS, Suh JD, Ramakrishnan VR. Treatment of cerebrospinal fluid rhinorrhea. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (01) 59-64
• 11 Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2012; 147 (02) 196-203
• 12 Caballero N, Bhalla V, Stankiewicz JA, Welch KC. Effect of lumbar drain placement on recurrence of cerebrospinal rhinorrhea after endoscopic repair. Int Forum Allergy Rhinol 2012; 2 (03) 222-226
• 13 Albu S, Emanuelli E, Trombitas V, Florian IS. Effectiveness of lumbar drains on recurrence rates in endoscopic surgery of cerebrospinal fluid leaks. Am J Rhinol Allergy 2013; 27 (06) e190-e194
• 14 Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH. Outcomes of endoscopic repair of cerebrospinal fluid rhinorrhea without lumbar drains. Am J Rhinol Allergy 2016; 30 (06) 424-429
• 15 Keshri A, Jain R, Manogaran RS, Behari S, Khatri D, Mathialagan A. Management of spontaneous CSF rhinorrhea: an institutional experience. J Neurol Surg B Skull Base 2019; 80 (05) 493-499
• 16 McCormick JP, Tilak A, Lampkin HB. et al. An expedited intracranial pressure monitoring protocol following spontaneous CSF leak repair. Laryngoscope 2021; 131 (02) E408-E412
• 17 Mirza S, Thaper A, McClelland L, Jones NS. Sinonasal cerebrospinal fluid leaks: management of 97 patients over 10 years. Laryngoscope 2005; 115 (10) 1774-1777
• 18 Vinciguerra A, Dohin I, Daloiso A. et al. Iatrogenic cerebrospinal fluid leak in endoscopic sinus surgery: topographical map and influence of skull base asymmetry. J Pers Med 2024; 14 (03) 226
• 19 Konuthula N, Khan MN, Del Signore A, Govindaraj S, Shrivastava R, Iloreta AM. A systematic review of secondary cerebrospinal fluid leaks. Am J Rhinol Allergy 2017; 31 (06) 48-56
• 20 Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000; 110 (07) 1166-1172
• 21 Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Laryngoscope 2017; 127 (09) 2011-2016
• 22 Schuknecht B, Simmen D, Briner HR, Holzmann D. Nontraumatic skull base defects with spontaneous CSF rhinorrhea and arachnoid herniation: imaging findings and correlation with endoscopic sinus surgery in 27 patients. AJNR Am J Neuroradiol 2008; 29 (03) 542-549
• 23 Georgalas C, Oostra A, Ahmed S. et al. International consensus statement: spontaneous cerebrospinal fluid rhinorrhea. Int Forum Allergy Rhinol 2021; 11 (04) 794-803
• 24 Jiang ZY, McLean C, Perez C. et al. Surgical outcomes and postoperative management in spontaneous cerebrospinal fluid rhinorrhea. J Neurol Surg B Skull Base 2018; 79 (02) 193-199
• 25 Bidot S, Levy JM, Saindane AM. et al. Spontaneous skull base cerebrospinal fluid leaks and their relationship to idiopathic intracranial hypertension. Am J Rhinol Allergy 2021; 35 (01) 36-43
• 26 Schmitt B, Badet JM, Chobaut JC, Tavernier L. Double skull base defects with primary spontaneous cerebrospinal fluid leaks in a single patient: temporal and sphenoid bones. Skull Base 2010; 20 (06) 455-458
• 27 Filip P, Patel EA, Khalife S. et al. Multiple skull base defects in the setting of spontaneous cerebrospinal fluid rhinorrhea; a dual institution view. Am J Otolaryngol 2024; 45 (01) 104048