Endoscopic management of frontal sinus CSF leaks / Manejo endoscópic de fístulas liquóricas do seio frontal

Abstract Introduction: Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition. Objective: To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach. Methods: A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined. Results: Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 - 41 months). Conclusion: Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Resumo Introdução: O manejo endoscópico das fístulas liquóricas do seio frontal tornou-se o padrão-ouro, com altas taxas de sucesso e baixa morbidade. Objetivo: Revisar nossa experiência no tratamento de fístulas liquóricas do seio frontal por meio de uma abordagem endoscópica endonasal. Método: Foi feita uma avaliação retrospectiva de pacientes submetidos à cirurgia endoscópica para fístulas liquóricas do seio frontal. Dados demográficos, localização e etiologia do defeito, técnica cirúrgica e reconstrutiva, complicações e seguimento pós-operatório foram analisados. Resultados: Foram tratados cirurgicamente pelo autor principal 22 pacientes com média de 40,4 anos entre 2015 e 2019. A fístula liquórica foi traumática (17) ou espontânea (5). O reparo endoscópico foi feito com sucesso na primeira tentativa em todos os casos. Uma abordagem combinada de trefinação e endoscopia foi necessária em 5 pacientes (22,8%). Nenhuma complicação grave foi relatada e a via de drenagem do seio frontal estava patente em todos os nossos casos. A cirurgia de revisão foi necessária em apenas 2 pacientes devido à formação de sinéquia. O seguimento médio dos pacientes foi de 22,7 meses (variação: 7 a 41). Conclusão: O progresso no campo da cirurgia endoscópica mudou o paradigma, estabeleceu o reparo endoscópico de fístulas liquóricas do seio frontal como o padrão de tratamento. Alguns poucos limites remanescentes dessa abordagem podem ser resolvidos pela combinação da endoscopia com a trefinação frontal.

A Prospective Study on Outcome of Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea

Background: Cerebrospinal fluid (CSF) rhinorrhea is the result of an osseous defect in the skull base coupled with a disruption of duramater and arachnoid mater with a resultant pressure gradient, leading to CSF leak. CSF leak can be categorized into spontaneous(idiopathic), traumatic, and non-traumatic. Endoscopic transnasal approach is an extracranial approach which has the advantage ofbeing less invasive, no external scar, excellent site localization with preservation of the surrounding anatomy, and shorter hospital stay.Aim of the Study: The aim of the study was to assess the outcome of repair, cause, site of leak, and efficacy of materials usedfor the repair, elucidate the advantages of endoscopic approach.Materials and Methods: A total of 25 patients with CSF rhinorrhea arising from anterior and middle cranial fossa not subsidingwith medical management were included in this prospective study. Patients of all ages and gender were included in the study.Patients with recent history of meningitis were excluded from the study. All the patients were evaluated for CSF rhinorrhea usingbattery of tests including clinical examination for reservoir sign, biochemical and microbiological analysis of fluid, radiologicalinvestigations, and diagnostic nasal endoscopy to assess the site of leak. The demographic data, CSF leak site and size, etiology,complications, surgical closure techniques, complications of surgery, and recurrences and its management were observed andrecorded. All the data were analyzed using standard statistical methods.Observation and Results: Among the 25 patients, 14/25 (56%) patients were aged below 30 years followed by 11/25 (44%)patients who were aged between 30 and 60 years. The mean age was 34.20 ± 2.35 years. 16/25 (64%) patients were (64%)female and 9/25 (36%) patients were male. 22/25 patients (88%) had spontaneous leaks and 3 patients (12%) had traumaticleaks. In 18/25 (72%) of the patients, the site of leak was in the cribriform plate, 4/25 (16%) from fovea ethmoidalis, 2/25(8%)from the sphenoid, and 1/25 (4%) from the frontal sinus. Immediate post-operative results were observed in 23/25 (92%) of thepatients and there was no CSF leak. 2/25 (8%) patients had CSF leak for 10 days which later subsided.Conclusions: The most common etiology of CSF rhinorrhea was spontaneous, most common site being the cribriform plate.Autologous fat graft was used as the first layer of underlay technique in most of the cases which act as a good sealant. The efficacyof transnasal endoscopic CSF leak repair in our study was found to be 100%, and it is a highly successful and safe procedure.

Atresia de coanas, revisión y una mirada desde la evidencia / Choanal atresia, review and a look from the evidence

La atresia de coanas es la anomalía congénita nasal más común. Cuando es bilateral, se presenta con dificultad respiratoria desde el nacimiento. La atresia unilateral se manifiesta con insuficiencia ventilatoria y rinorrea unilateral, pudiendo pasar inadvertida. El diagnóstico se sospecha ante la ausencia de paso de aire en las fosas nasales y la imposibilidad de hacer progresar una sonda nasogástrica. Se confirma mediante examen endoscópico y tomografía computarizada. El tratamiento definitivo es quirúrgico, existiendo diferentes técnicas y vías de abordaje. Se presenta una revisión de la literatura, con especial énfasis en el tratamiento pos-quirúrgico con stents y mitomicina-C a través de una mirada desde la evidencia.

Choanal atresia is the most common congenital nasal anomaly. When bilateral, it presents with respiratory distress at birth. Unilateral atresia is manifested by respiratory failure and unilateral rhinorrhea, and may go along unnoticed. Diagnosis is suspected in the absence of airflow in the nasal cavity and for the inability to advance a nasogastric tube. Diagnosis is confirmed by endoscopic examination and computed tomography. The definitive treatment is surgical, and there are different techniques and surgical approaches. A review of the literatureis presented, with special emphasis onthepost-surgical treatmentwithstents and Mitomycin-Cview from the evidence.

Atresia coanal congénita unilateral en paciente adulto: presentación de un caso y revisión bibliográfica sobre vías de abordaje: complicaciones y tratamientos adicionales / Unilateral congenital choanal atresia in adult patient: case report and bibliographical review about surgical approaches, complications and additional treatments

La atresia de coanas, es una patología poco frecuente, que habitualmente se diagnostica en las edades tempranas. Representa un reto quirúrgico por su alta tendencia a la reestenosis, considerándose en la actualidad de elección el tratamiento endoscóplco. Tratamientos como stents posoperatorios o la aplicación de mitomicina C tópica para disminuir la reestenosis son todavía controvertidos, sin que exista consenso. Presentamos el caso de un adulto con atresia de coana unilateral que se reparó vía endoscópica transnasal y se realiza una revisión bibliográfica sobre el estado actual del tratamiento de esta patología.

Choanal atresia is a very rare condition, usually it's diagnosticated in early age. It represents a surgical challenge for the high tendency to restenosis, being actually the endoscopic treatment first option. Other treatments like postoperative stents or topical mitomycin-C in order to avoid restenosis are controversial, and there is a lack of consensus. We present an adult case with unilateral choanal atresia treated by transnasal endoscopic technique and It's carry out a bibliographical review about the current treatment state of this pathology.

Extended Application of Endoscopic Repair for Frontal Sinus Fractures

PURPOSE: The coronal approach for repair of frontal sinus fractures is associated with significant adverse sequelae including a long scar, alopecia, paresthesias, and, uncommonly, facial nerve injury. To minimize these complications, an endoscopic approach for repair of frontal sinus fractures was developed. The authors now present the results of an endoscopy-assisted approach for the treatment of frontal sinus fractures. METHODS: From 2002 to 2009, five patients with frontal sinus fracture underwent endoscopic repair. Two slit incisions were placed in the scalp, and one or two stab incisions directly over the fractures were placed in the forehead. After subperiosteal dissection, fracture segments were reduced under direct vision and fixed with microplates or fibrin glue. RESULTS: All patients had good cosmetic results and remained free of sinus complaints. There were no perioperative complications reported. CONCLUSION: Endoscopic repair of frontal sinus fractures is an efficacious technique that significantly reduces patient morbidity. A relatively wide range of anterior table fractures can be reduced using an endoscope. In cases of complicated comminuted fractures, fibrin glue helps to achieve satisfactory endoscopic reduction. Endoscopic repair is an alternative treatment for various anterior table fractures of the frontal sinus.

A Case of Post-Traumatic Cerebrospinal Fluid Rhinorrhea with Encephalocele / 대한이비인후과학회지

Posttraumatic cerebrospinal fluid (CSF) leakage may frequently develop after a skull base fracture. A patient with a 1-month history of intermittent watery rhinorrhea was referred to our department from the Department of Neurosurgery. He had been treated for 8 months due to a skull base fracture after a motor vehicle accident. He had undergone cranial trephination due to brain abscess prior to this presentation. On radiologic examination, a large skull base defect with encephalocele was observed. Using the nasal endoscopic approach, we identified a large protruding mass of soft brain tissue with pulsating CSF in the ethmoid roof. CSF lumbar drainage was performed in order to reduce the protruding mass by decreasing intracranial pressure. After CSF lumbar drainage, the protruding brain tissue was returned to the cranial cavity, and the leak site was successfully repaired with septal cartilage and graft material.

Two Cases of Spontaneous Cerebrospinal Fluid Rhinorrhea by Idiopathic Bony Defects / 대한이비인후과학회지

Cerebrospinal fluid rhinorrhea can be caused by head trauma, brain or sinus surgery or neoplastic sinonasal disease. In addition, CSF rhinorrhea may develop spontaneously in some cases. We experienced two cases of spontaneous CSF rhinorrhea caused by idiopathic bony defect. The first case was a 47-year old female who complained of a persistent rhinorrhea for 2 months without surgical or traumatic history. The second case was a 40-year old female. Having no surgical or traumatic history, she also suffered from a persistent rhinorrhea for thirteen years. For diagnosis of CSF rhinorrhea, we carried out endoscopic examination, glucose test of rhinorrhea, computed tomograph, magnetic resonance imaging and (99m)Tc-DTPA cisternography. We found bony defect in the cribriform plate of the two cases. Patients were treated successfully with endoscopic approach. Leak sites were repaired with free graft materials. There has not been any recurrence or complications since the endoscopic closure.

A Case of Encephalomeningocele Presenting with Cerebrospinal Fluid Rhinorrhea: Endoscopic Endonasal Removal with Repair / 대한이비인후과학회지

Encephalomeningocele is a rare disease presenting extracranial protrusion of the brain and meninges through the skull base defect. The authors experienced a case of cerebrospinal fluid (CSF) rhinorrhea developing from encephalomeningocele which was protruded into the nasal cavity through the cribriform plate. It was repaired successfully with septal bone and middle turbinate mucosa under nasal endoscopy. The radiologic features and techniques for the endoscopic management of meningoencephalocele with CSF rhinorrhea are discussed.

Surgical Repair of Cerebrospinal Fluid Rhinorrhea with Mucoperichondrial Free Graft

Three cases of cerebrospinal fluid (CSF) rhinorrhea and anterior skull base defects were successfully treated by applying mucoperichondrial free graft through the endonasal endoscopic technique. The causes of the skull base defects were trauma in two cases and endoscopic sinus surgery in one case. The defects were located in the sphenoid sinus in one case and the fovea ethmoidalis in two cases. In these cases, contralateral side septal mucoperichondrial free grafts were used to seal the defects and were supported with fibrin glue and Spongostan(R). Endoscopic repair with mucoperichondrial free graft appeared to be a safe and successful approach to the treatment of the anterior skull base defects.

Intranasal Endoscopic Management of Cerebrospinal Fluid Rhinorrhea

BACKGROUND: Management of patients with cerebrospinal fluid (CSF) rhinorrhea remains controversial. OBJECTIVE: The therapeutic effect of endoscopic repair of CSF rhinorrhea was evaluated. METHOD: Sixteen patients with CSF rhinorrhea involving the anterior skull base underwent intranasal endoscopic management between 1991 and 1998. Repair materials included free nasal mucosa, muscle tissue and myofascia. RESULTS: Of the sixteen patients, ten were results of head trauma, three were results of endoscopic surgery, two were at the postoperative stage of meningoma, and one was at the postoperative stage of hypophyseal adenoma. Fourteen patients had one fistula and the others two. During follow-ups lasting five months to six years, all of the cases were successfully treated without complication either intra- or post-operatively on the first attempt. CONCLUSION: The endoscopic technique provides a safe and effective means for repairing many patients with CSF rhinorrhea. Some key points to keep in mind when applying this techniques are to prepare a fresh graft recipient site and to embed free muscle into the intracranial cavity through the entrance of the dural defect.

Endoscopic Laser-Assisted Repair in a Case of Acquired Bilateral Choanal Stenosis

The operative methods for the choanal atresia or stenosis are transseptal, transnasal, transpalatal and transmaxillary approaches. Among them, endoscopic transnasal approach provides excellent visualization and little age limitation. The use of CO2 laser in the management of choanal atresia enables the accurate incision and vaporization. We experienced a case of acquired bilateral choanal stenosis which developed after external irradiation for nasopharyngeal carcinoma. She presented with the symptoms of slowly progressive bilateral nasal obstruction and persistent nasal discharge for the past three years prior to visiting hospital. We successfully managed her by endoscopic transnasal repair with CO2 laser and found this technique to safe and simple.