Purely Endoscopic Repair of Traumatic Cerebrospinal Fluid Rhinorrhea From the Anterior Skull Base -Case Report-

Abstract

A 38-year-old woman presented with a case of post-traumatic ethmoidal cerebrospinal fluid (CSF) leak that was repaired using a purely endoscopic endonasal approach. Six weeks after a mild domestic maxillofacial trauma, she started complaining of clear, watery discharge from the left nostril and headache. Neuroimaging investigations disclosed a linear fracture of the left anterior ethmoidal roof without evidence of large bony breaches or any brain tissue damage. After conservative medical treatment with carbonic anhydrase inhibitors failed, she was referred to our hospital for surgical repair of the osteodural defect. An endoscopic endonasal transethmoidal approach was successfully performed, and an overlay technique was used to reconstruct the defect. The patient was discharged without clinical evidence of CSF rhinorrhea and no leaks were apparent at the 3-month follow-up clinical and radiological examinations. Post-traumatic CSF rhinorrhea occurs in cases of dural tears associated with small bone breaks, most frequently involving the anterior skull base. Recovery is often spontaneous following only bed rest, or with medical treatments such as inhibitors of carbonic anhydrase diuretics, steroids, or eventually stool softeners to help reduce CSF pressure. Surgical repair is required when first-line conservative treatment proves ineffective. The present case shows that the endoscopic endonasal technique for the management of CSF leaks provides a less invasive surgical route to achieve valid dural repair.

Endoscopic endonasal multilayer repair of traumatic CSF rhinorrhea

“…These advantages include accurate localization of the defect, preservation of olfaction in most cases, no brain retraction especially on the frontal lobe, less morbidity and less hospital stay. However, several authors have reported variable success rates [5][6][7] apparently due to differences in their diagnostic protocols, repair techniques, and other factors.…”

Spontaneous cerebrospinal fluid leak at the clivus.

“…Transcranial approaches require cerebral retraction, which increases the risk of brain swelling, hematoma and injuries of the internal carotid artery, basal artery and the optic nerve. The use of anterior approaches, namely transnasal, transoral and transfacial approaches, may significantly reduce these complications [ 7 – 10 ]. Endoscopic surgery creates a new method for the management of spontaneous CSF leaks within the clivus region and facilitates good visualization of critical structures [ 2 ].…”

Cerebrospinal Fluid Rhinorrhea and Subsequent Bacterial Meningitis due to an Atypical Clival Fracture

“…Patients with persistent CSF rhinorrhea may require surgical therapy such as endoscopic endonasal repair and sinus obliteration or cranialization because 20% of these cases will develop bacterial meningitis ( 2 ). The common sites of origin for CSF rhinorrhea after anterior skull-base trauma include the cribriform plate, the roof of the sphenoid sinus, and the posterior wall of the frontal sinus, because the dura mater is strictly adherent to the bone at these sites ( 5 ). The clivus is the deepest bone of the skull base and is rarely injured.…”