Download PDF
Minim Invasive Neurosurg 2005; 48(3): 175-180
DOI: 10.1055/s-2005-870904
Original Article
© Georg Thieme Verlag Stuttgart · New York

Transnasal Endoscopic Repair of Cerebrospinal Fluid Fistulas and Encephaloceles: Surgical Indications and Complications

E.  Marton1 , D.  Billeci1 , E.  Schiesari2 , P.  Longatti1
  • 1Neurosurgical Department, Regional Hospital, Treviso, Italy
  • 2Otorhinolaryngological Department, San Donà Hospital, Treviso, Italy
Further Information

Publication History

Publication Date:
13 July 2005 (online)

    Permissions and Reprints

Abstract

Introduction: Transnasal endoscopic repair of cerebrospinal fluid (CSF) fistulas is recommended for patients with CSF leaks who do not respond to conservative treatment. It is a safer and more successful alternative to transcranial surgery. Patients and Methods: We present our experience on using transnasal endoscopy for the repair of anterior skull base cerebrospinal fluid fistulas. Between 1999 and 2003 we observed 20 patients with CSF rhinorrhea. The etiology was heterogeneous: post-traumatic in 6 cases, iatrogenic in 6 cases (one interesting case of meningioma of the sphenoethmoid plate), dysembryogenetic - due to encephaloceles - in 4 patients (one with Cruzon syndrome and one with Down syndrome) and idiopathic in the other 4 patients. Use of a rigid transnasal endoscope allowed the localization and repair of all fistulas, with the use of fluorescein in 6 cases. Different grafts were used, in particular fat, bone or chondral septum with mucoperiosteum or perichondral mucosa. Generally the graft was inserted with the underlay or the sandwich technique. Lumbar drainage was used in the postoperative period only in 6 cases. No antibiotic prophylactic therapy was used. Results: Endoscopy was successful in 90 % of patients at the first attempt, and in 95 % of patients at the second approach. We had two late complications such as infections. In one child with a post-traumatic fistula and shunt for hydrocephalus, we observed meningitis 2 years after the first endoscopic surgery and he underwent both transnasal endoscopic surgery and transcranial surgery. The second patient was a woman with a spontaneous fistula, who had rhinoliquorrhea three years after the first surgical treatment. During surgery a strange similar purulent material filling the submucous space of the ethmoid roof was found, suggestive for an intranasal abscess that was removed. We did not see any complications such as hematomas or seizures. The follow-up (range: 6 months to 3 years) made both with MRI and rhinoscopy has not shown any relapse until now in 19 of 20 patients treated only with endoscopy. Conclusions: The endoscopic approach is highly effective and safe in the treatment of CSF fistulas, with great visualization and minimal invasiveness, for which it is associated to a very low morbidity. The fluorescein technique is extremely helpful for the diagnosis and surgery of CSF leaks.

Key words

Cerebrospinal fistula - transsphenoidal endoscopy - encephalocele

References

  • 1 Nandapalan V, Watson I D, Swift A C. Beta 2 transferrin and cerebrospinal fluid rhinorrhea.  Clin Otolarygol. 1996;  21 259-264
    CrossrefPubMedGoogle Scholar
  • 2 Eljamel M S, Foy P M. Post traumatic CSF fistulae, the case for surgical repair.  Br J Neurosurg. 1990;  4 479-483
    CrossrefPubMedGoogle Scholar
  • 3 Aarabi B, Leibrock L G. Neurosurgical approaches to cerebrospinal fluid rhinorrhea.  Ear Nose Throat J. 1992;  71 300-305
    PubMedGoogle Scholar
  • 4 Bibas A G, Skia B, Hickey S A. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea.  Br J Neurosurg. 2000;  14 49-52
    CrossrefPubMedGoogle Scholar
  • 5 Hubbard J L, McDonald T C, Pearson B W. Spontaneous cerebrospinal fluid rhinorrhea: evolving concepts in diagnosis and management based on the Mayo Clinic experience from 1970 to 1981.  Neurosurgery. 1985;  16 314-321
    CrossrefPubMedGoogle Scholar
  • 6 Park J I, Strelzow V V, Friedman W H. Current management of cerebrospinal fluid rhinorrhea.  Laryngoscope. 1983;  93 1294-1300
    CrossrefPubMedGoogle Scholar
  • 7 Bartley J. Extracranial repair of cerebrospinal fluid rhinorrhoea.  Aust NZ Surg. 1998;  68 359-362
    PubMedGoogle Scholar
  • 8 Dohlman G. Spontaneous cerebrospinal rhinorrhea.  Acta Otolaryngol Suppl (Stockh). 1948;  67 20-23
    PubMedGoogle Scholar
  • 9 Hirsch O. Successful closure of cerebrospinal fluid rhinorrhea by endonasal surgery.  Arch Otolaryngol. 1952;  56 1-13
    CrossrefPubMedGoogle Scholar
  • 10 Vrabec D P, Hallberg O E. Cerebrospinal fluid rhinorrhea.  Arch Otolaryngol. 1964;  80 218-229
    CrossrefPubMedGoogle Scholar
  • 11 Mattox D E, Kennedy D W. Endoscopic management of cerebrospinal fluid leaks and encephaloceles.  Laryngoscope. 1990;  100 857-862
    Google Scholar
  • 12 Wigand W E. Transnasal ethmoidectomy under endoscopic control.  Rhinology. 1981;  19 7-15
    PubMedGoogle Scholar
  • 13 Calcaterra T C. Extracranial surgical repair of cerebrospinal fluid rhinorrhea.  Ann Otol Rhinol Laryngol. 1980;  89 108-116
    PubMedGoogle Scholar
  • 14 Dodson E E, Gross C W, Swerdloff J L, Gustafson L M. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases.  Otol Head Neck Surg. 1994;  111 600-605
    CrossrefPubMedGoogle Scholar
  • 15 Persky M S, Rothstein S G, Breda S D. Extracranial repair of cerebrospinal fluid otorhinorrhea.  Laryngoscope. 1991;  101 134-136
    PubMedGoogle Scholar
  • 16 Burns J A, Dodson E E, Gross C W. Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up.  Laryngoscope. 1996;  106 1080-1083
    PubMedGoogle Scholar
  • 17 Lanza D C, O'Brien D A, Kennedy D W. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles.  Laryngoscope. 1996;  106 1119-1125
    CrossrefPubMedGoogle Scholar
  • 18 Mao V H, Keane W M, Atkins J P. Endoscopic repair of cerebrospinal fluid rhinorrhea.  Otolaryngol Head Neck Surg. 2000;  122 56-60
    CrossrefPubMedGoogle Scholar
  • 19 Schick B, Brors D, Ibing R, Draf W. Long term study of endonasal duraplasty and review of the literature.  Ann Otol Rhinol Laryngol. 2001;  110 142-147
    PubMedGoogle Scholar
  • 20 Zweig J L, Carrau R L, Celin S E. Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success.  Otolaryngol Head Neck Surg. 2000;  123 195-201
    CrossrefPubMedGoogle Scholar
  • 21 Gupta V, Goyal M, Mishra N. MR evaluation of CSF fistulae.  Acta Radiol. 1997;  38 603-609
    PubMedGoogle Scholar
  • 22 Johnson D BS, Toland B J, O'Dwyer A J. Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistulae.  Clin Radiol. 1996;  51 837-841
    CrossrefPubMedGoogle Scholar
  • 23 Zapalac J S, Marple B F, Schwade N D. Skull base cerebrospinal fluid fistulas: A comprehensive diagnostic algorithm.  Otolaryngol Head Neck Surg. 2002;  126 669-676
    CrossrefPubMedGoogle Scholar
  • 24 Shetty P G, Shroff M M, Sahani D V. Evaluation of high resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula.  Am J Neuroradiol. 1998;  19 633-639
    PubMedGoogle Scholar
  • 25 Reilly P, Krishnan S. Cerebrospinal fluid fistula. In: Kaye AH, Black PMcL (Eds), Operative Neurosurgery. London, Churchill Livingstone 2000: 265-277
    Google Scholar
  • 26 Spetzler R F, Zabramski J M. Cerebrospinal fluid fistula.  Contemp Neurosurg. 1986;  8 1-7
    PubMedGoogle Scholar
  • 27 Mehendale N H, Marple B F, Nussenbaum B. Management of sphenoid sinus cerebrospinal fluid rhinorrhea: Making use of an extended approach to the sphenoid sinus.  Otolaryngol Head Neck Surg. 2002;  126 147-153
    CrossrefPubMedGoogle Scholar
  • 28 Roland P S, Marple B F, Meyerhoff W L. Complications of lumbar spinal fluid drainage.  Otolaryngol Head Neck Surg. 1992;  107 564-569
    PubMedGoogle Scholar
  • 29 Zeitouni A G, Freinkeil S, Mohr G. Endoscopic repair of anterior skull base CSF fistulas: An emphasis on postoperative function maximisation.  J Otolaryngol. 1994;  23 225-227
    PubMedGoogle Scholar
  • 30 Hughes R GM, Jones N S, Robertson I JA. The endoscopic treatment of cerebrospinal fluid rhinorrhoea: the Nottingham experience.  J Laryngol Otol. 1997;  111 125-128
    PubMedGoogle Scholar
  • 31 Herman P, Lot G, Guichard J P. Mucocele of the sphenoid sinus: a late complication of transsphenoidal pituitary surgery.  Ann Otol Rhinol Laryngol. 1998;  107 765-768
    PubMedGoogle Scholar

Dr. Elisabetta Marton

Neurosurgical Department · Regional Hospital

Piazzale Ospedale

31100 Treviso

Italy

Phone: +39-0422-322-576

Fax: +39-0422-322-523

Email: emarton@ulss.tv.it

      >