Endoscopic Endonasal Approach for Cerebrospinal Fluid Fistulae

Abstract

Different techniques have been proposed to repair cerebrospinal fluid rhinorrhea. Advances in nasal surgery led to a high success rate and low morbidity for the endonasal approach. It has become the favorite route for treating cerebrospinal fluid leaks of the anterior skull base. Better results have been obtained with the improvement of rigid endoscopes and intrathecal sodium fluorescein. In a prospective study, twenty-four patients with cerebrospinal fluid rhinorrhea were evaluated and treated by endoscopic endonasal surgery. In all cases intrathecal sodium fluorescein enabled a precise localization of the bone defect. The most common causes of CSF rhinorrhea were traumatic (8 cases, 33 %), spontaneous (6 cases, 25 %), and iatrogenic (5 cases, 20.8 %). Preoperative radiological evaluations (plane CT, CT cisternogram and MRI) showed the exact site and size of the defect in all patients. The most common site of leakage was the ethmoidal roof-cribriform plate. Primary closure was achieved in all patients. There were no major operative or postoperative complications. The endoscopic endonasal approach can be considered the first choice in the treatment of cerebrospinal fluid rhinorrhea.

Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures

“…72,80 Various authors have successfully used different types of autologous and nonautologous grafts, such as a mucoperiosteal flap from the middle turbinate or septum or mucoperichondrial, osseous, cartilaginous, fat, muscular fascia, middle turbinate, or septum pedunculated graft, or any combination of these grafts. 1,3,11,13,15,22,[24][25][26]28,35,47,51,55,56,64,65,67,77,79,90,101,108 Another widely discussed issue in endoscopic transnasal repair is whether the grafts used for repair should be placed above (inlay) or beneath (onlay) the skull base defects. In a meta-analysis, Hegazy et al 53 found that both techniques yielded similar results.…”

Nontraumatic Skull Base Defects With Spontaneous CSF Rhinorrhea and Arachnoid Herniation: Imaging Findings and Correlation With Endoscopic Sinus Surgery in 27 Patients

“…The occurrence of osteodural leaks along the course of the anterior ethmoid artery in 8 of 15 patients indicates reduced skull base resistance at this location, which previously has been noticed as a common site for posttraumatic CSF fistulas only. 43 Recognition of the course of the anterior ethmoid artery on imaging is crucial to avoid complications during endoscopic treatment. 44 As far as imaging is concerned, arachnoid herniation has hardly been recognized as an important finding in conjunction with osteodural defects.…”

“…However, 2 patients with defects in the paramedian sphenoid sinus location have been reported by Silva and coworkers. 43 Lopatin and coworkers 14 describe a midline fistula site in 4 of 9 patients with a sphenoid sinus location of spontaneous CSF leaks. During endoscopic surgery, leaks presented with arachnoid herniation as demonstrated in Figs 1C and 4D in our series.…”

Endoscopic transnasal approach for removing pituitary tumors

“…The success rate in the removal of pituitary tumors through the endoscopic transnasal approach is comparable to or higher than that of the microsurgical technique, reaching more than 95% of total removal id n cases of adenomas 7,30 . In summary, the series were found to be higher than in most of the studies reviewed 6,7,12,15,16,17,19,20,24,26,30,31 . The clinical application to this find is that the insertion of this modern technique slightly invasive should be encouraged once they can be performed in large hospitals funded by the public health system and operated by a integrated multiprofessional team.…”