Endoscopic repair of cerebrospinal fluid rhinorrhoea

Background Endoscopic skull‐base surgery (ESBS) is employed in the management of diverse skull‐base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull‐base surgery have produced the International Consensus Statement on Endoscopic Skull‐Base Surgery (ICAR:ESBS). Methods Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence‐based review or evidence‐based review with recommendations format. Subsequently, each topic was written and then reviewed by skull‐base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. Results The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull‐base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. Conclusion A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence‐based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull‐base community to embrace these opportunities and collaboratively address these shortcomings.

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“…However, endoscopic repair of traumatic CSF leaks is a well‐accepted treatment with a low complication rate. {Banks, 2009 #3115}…”

Section: Primary Csf Rhinorrheamentioning

confidence: 99%

ICAR: endoscopic skull‐base surgery

Wang

Zanation

Gardner

et al. 2019

Int Forum Allergy Rhinol

157

279

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“…The reported success rates ranged from 60% to 100% (12,27,32). In our series of 26 patients with VMSBL, the primary success rate of endoscopic endonasal approach was 88.5% on the first attempt and increased to 96% after the second operation.…”

Section: A B C D E F G Hmentioning

confidence: 75%

“…Systematic reviews on endoscopic repair of CSF leaks have described the ethmoidal roof and the cribriform region as the most frequently involved sites (27,32). Accordingly, crista galli was the most common site in our series (48.2%), followed by the posterior ethmoidal cells (20.7%), the sphenoid sinus (20.7%), and the anterior ethmoidal cells (10.4%).…”

Section: A B C D E F G Hmentioning

confidence: 81%

“…In a recent review article, Sharma et al did not reach a final conclusion on the best available material for endoscopic repair of CSF fistulas (32). However, in our cases, high-pressure and large-diameter leaks needed inlay free fascia grafts and all were held in place by 4.0 vicryl suture at the center of the graft.…”

Section: A B C D E F G Hmentioning

confidence: 94%

“…The majority of our cases with CSF leak comprised spontaneous (62%), followed by traumatic (27%) and iatrogenic (11%) causes. Some recent studies emphasized trauma as the most common cause of CSF leaks (32), whereas most of the available meta-analyses in literature cited spontaneous etiology as the most common (27).…”

Section: A B C D E F G Hmentioning

confidence: 99%

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Endoscopic endonasal cerebrospinal fluid leak repair on the ventral midline skull base: a single neurosurgical center experience

İşler

Ahmedov²,

Akgün³

et al. 2017

Turkish Neurosurgery

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CSF leaks have been grouped into three distinct etiologic categories, namely, traumatic, spontaneous, and iatrogenic (due to previous operation). Furthermore, each group has been subdivided into acute and delayed types (6). The first line of treatment is surgery in all cases of spontaneous etiology and in most cases of iatrogenic cause of skull base CSF leak (36,38). On the contrary, initial conservative management has been advocated for traumatic CSF leaks (8,12). When conservative management fails, usually at the end of two weeks, surgical management of rhinorrhea is mandatory in traumatic cases (16,28). (7,10,18,19,22,29). A connection to the subarachnoid space, most likely associated with a disruption of the arachnoid and dura mater with accompanying bone defect, is a prerequisite for CSF leak and inevitably carries a risk for ascending infection to the intracranial space (15,25,26,31). AIM:To present the results of endoscopic endonasal repair of ventral midline skull base cerebrospinal fluid (CSF) leak (VMSBL) at our institution and to discuss the technique and results from a neurosurgical perspective. MATERIAL and METHODS:A retrospective analysis of all VMSBL cases that underwent endoscopic endonasal skull base approach (EESBA) for CSF leak repair at a single tertiary neurosurgical center was performed. Twenty six patients with an average age of 44.4 (range: 17-63) years were included in the study. RESULTS:The etiology of VMSBL was spontaneous in 16 patients, traumatic in 7, and iatrogenic in 3. The leakage site was the cribriform plate in 13 patients, ethmoidal cells in 7, and sphenoid sinus in 3. There were multiple leaks in 3 patients. This approach for VMSBL repair was performed 28 times on 26 patients. The success rate was 88.5% (23/26 patients) after primary endoscopic repair and 96% after the second attempt. The location of the leakage site relative to the upper attachment of the middle turbinate played a crucial role in the anteriorly located VMSBL, which made an impact on the surgical repair plan. All the 16 cases with accompanying meningoencephaloceles were treated successfully by EESBA. Use of vascularized pedicled flaps to support the repair site resulted in 100% success after primary repair. CONCLUSION:EESBA is safe and highly effective and can be a first-line surgical treatment option for VMSBL. In addition, it enables adequate reconstruction of ventral midline skull base meningoencephaloceles regardless of size and location.

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