A Clinical Case of Delayed Posttraumatic Frontal Sinus Cerebrospinal Fluid Leakage Management Via External Surgical Approach

Abstract

: Cerebrospinal fluid rhinorrhea is frequently encountered after a fracture of the skull base. Individual fractures of the posterior wall of the frontal sinus after brain injury are uncommon. The authors present a case of a 33-year-old man with a distant history of skull base injury after a traffic accident, 12 years ago. He presented with intermittent rhinorrhea and reported 2 episodes of bacterial meningitis the last 7 years since the injury. Cerebrospinal fluid leakage was confirmed with β2-transferrin testing. Computed tomography and magnetic resonance imaging revealed a small defect of the posterior and superior wall of the left frontal sinus and an ipsilateral meningoencephalocele. Finally, there was a communication between intracranial space and frontal sinus that caused meningitis. A coronal incision and frontal craniotomy with preservation of anterior pericranium was performed (frontal sinus cranialization using osteoplastic flap). In order to determine the precise margins of the frontal sinus and allow an accurate anterior table bone osteotomy and complete exposure of the sinus, the authors used a coronal view of skull X-ray. Scissors are then used to cut along the margins of the sinus. An “R” is scratched into the right side of template to record orientation. The template was sterilized and brought onto the surgical field and then placed over the left sinus An external surgical approach (anterior table bone osteotomy) with the modern technique of osteoplastic flap access was performed. An elevator was used to separate the dura from the posterior table along the entire margin of the defect. Meningoplasty (cauterization of the meningoencephalocele) and closure of the osseous defect was followed. The authors repaired the defect of the posterior wall of the left frontal sinus using a combination of underlay and overlay technique. Femoral fascia from right thigh and fibrin glue were placed in order to cover the leak of the posterior wall of the left frontal sinus, respectively. Patients who present with a short or/ and distant history of traumatic brain injury should be evaluated for complication of a cerebrospinal fluid leak.

Delayed CSF rhinorrhea presenting as a lethal acute bacterial meningitis 5 years post trauma

“…CSF rhinorrhea is not an uncommon complication of neurosurgical procedures or head trauma. 3 , 4 However, the presentation is usually early with more than 50% presenting within 48 h. Delayed presentations beyond a year are rare and are mostly limited to case reports. 7 Later presentations are associated with higher complication rates, especially of meningitis which can lead to significant morbidity and as in our case mortality.…”

“…CSF rhinorrhea is not an uncommon complication of neurosurgical procedures or head trauma 3,4 . However, the presentation is usually early with more than 50% presenting within 48 h. Delayed presentations beyond a year are rare and are mostly limited to case reports 7 .…”

“…1 The presentation is usually early, and delayed presentations after months or years are usually limited to case reports. [2][3][4] In cases that present late, the incidence of occurrence of meningitis increases, which may lead to significant morbidity. 5,6 In this report, we discuss a case of a young man who developed intermittent CSF rhinorrhea 4 years after a head trauma.…”

“…Cerebrospinal fluid (CSF) rhinorrhea may occur spontaneously, secondary to iatrogenic causes or post head trauma especially skull base fracture 1 . The presentation is usually early, and delayed presentations after months or years are usually limited to case reports 2–4 . In cases that present late, the incidence of occurrence of meningitis increases, which may lead to significant morbidity 5,6 .…”