Management of coexistent sinonasal pathology in patients undergoing endoscopic cerebrospinal fluid rhinorrhea repair / Manejo de doenças nasossinusais coexistentes em pacientes submetidos a tratamento cirúrgico endoscópico de fístula liquórica

Abstract Introduction Patients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair. Objective To study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea Methods A retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period. Results Of a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%). Conclusion Patients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.

Resumo Introdução Pacientes submetidos a tratamento cirúrgico endoscópico de fístula liquórica podem ocasionalmente apresentar coexistência de outras doenças comuns que podem ou não precisar ser tratadas antes do procedimento. Alguns pacientes podem desenvolver nova morbidade nasal relacionada ao tratamento da fístula. Objetivo Estudar a prevalência e o manejo de doenças nasossinusais adicionais em pacientes submetidos ao reparo endoscópico de fístula liquórica. Método Uma revisão retrospectiva de pacientes submetidos ao reparo endoscópico de fistula liquórica foi feita para avaliar a presença de outras morbidades nasossinusais coexistentes no pré‐operatório e no período de seguimento. Resultados De 153 pacientes submetidos ao tratamento endoscópico do fistula liquórica, 97 (63,4%) eram do sexo feminino e 56 (36,6%) do masculino. A maioria dos pacientes (90,2%) tinha entre 21 e 60 anos, com média de 40,8. Verificou‐se que 64 pacientes (41,8%) apresentavam coexistência de morbidade nasossinusal no pré‐operatório, as mais comuns eram desvio de septo nasal sintomático (17,6%), rinossinusite crônica sem pólipos (11,1%) e rinossinusite crônica com pólipos (3,3%). Casos raros de hemangioma septal (0,7%) e papiloma invertido (0,7%) também foram observados. No pós‐operatório, inicialmente obteve‐se fechamento da fístula liquórica em 96,7%, que aumentou para 100% após a cirurgia de revisão nos pacientes com recorrência. A resolução das outras doenças nasossinusais coexistentes foi obtida em todos os pacientes, o seguimento variou de 10 a 192 meses. A ocorrência de uma nova morbidade nasossinusal no pós‐operatório incluiu sinéquias entre a concha média e a parede lateral do nariz (5,9%) e polipose nasossinusal (1,3%). Conclusão Pacientes submetidos a tratamento endoscópico de fistula liquórica podem apresentar coexistência de outras doenças nasossinusais que necessitam de tratamento prévio ou concomitante ao reparo do defeito dural. Outras morbidades nasossinusais que surgem durante o pós‐operatório podem exigir tratamento adicional. Um protocolo para o manejo das condições nasossinusais coexistentes garante um desfecho bem‐sucedido.

Management and outcome of post-traumatic cerebrospinal fluid rhinorrhea

Background: Post-traumatic cerebrospinal fluid (CSF) rhinorrhea are relatively uncommon neurosurgical condition that is associated with serious morbidity and life-threatening complications like meningitis. As such, it requires prompt and thorough evaluation and treatment. Is of note that, only few studies discussed CSF rhinorrhea in literature especially in sub-Saharan Africa. This study was designed to report outcomes of management of post-traumatic CSF rhinorrhea seen in our institution.Methods: Relevant data of all patients with post-traumatic CSF rhinorrhea managed from July 2015 to June 2019 were retrospectively reviewed.Results: Out of the total 1942 cases of head injury managed over the study period 20 cases (1%) were diagnosed with CSF rhinorrhea. The mean age of presentation was 30.5 years. All patients were male and road traffic accidents was the only aetiological factor noted. Majority of patients developed rhinorrhea after 48 hours of injury (12/20). Pneumocephalus was the commonest computerised tomographic scan finding and about 2/3rd of the patients required operative treatment by transcranial anterior cranial fossa repair (13/20). The remaining patients were managed non-operatively with acetazolamide, antihistamines, stool softeners and antibiotics. The outcome was generally good with no recurrence noted. The rate of mortality was 10% (2/20) and resulted from meningitis.Conclusions: Posttraumatic CSF rhinorrhea was seen in 1% of cases of head injury in our environment and affects males predominantly. Although, the outcome of treatments was good, 10% mortality caused by meningitis was recorded.

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 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.

A Case of Pneumococcal Meningitis Associated with Posttraumatic Cerebrospinal Fluid Rhinorrhea / 대한소아신경학회지

Bacterial meningitis after head trauma is a rare complication, but the cerebrospinal fluid(CSF) leakage after head trauma greatly increases the risk of bacterial meningitis. Most of the infections passes through the defects in the basal skull fracture, and Streptococcus pneumoniae is the most common organism. MRI, coronal thin sections of cranial CT and radioiosotope cisternography are considered to diagnose the CSF fistulae. We report a case of a 14-year-old girl with pneumococcal meningitis complicated by CSF rhinorrhea following an asymptomatic period of 3 years after head trauma. We found a bone defect of the cribrium of the skull base by means of paranasal sinus CT scanning and MRI.

Tension Pneumocephalus after Transsphenoidal Surgery for a Giant Pituitary Tumor: Case Report

Tension pneumocephalus is a rare complication of craniotomy, however, it should be managed promptly due to rapid neurological deterioration. We report a case of tension pneumocephalus after transsphenoidal surgery for a giant pituitary tumor. It may have developed because of the cerebrospinal fluid rhinorrhea and presence of an external lumbar drain.

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.

A Case of Cerebrospinal Fluid Rhinorrhea Associated with Primary Empty Sella Syndrome / 대한이비인후과학회지

The empty sella syndrome is applied to the abnormal extension into the sella turcica of an arachnoid diverticulum filled with CSF, which displace and compresses the pituitary gland. Such a diverticulum can erode the sellar floor and lead to CSF rhinorrhea through the sphenoid sinus. Recently we experienced a case of the spontaneous CSF rhinorrhea associated with the empty sella syndrome in a 55 year-old woman. The CSF leakage was repaired successfully by sublabial, transseptal, transsph-enoidal approach.

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.

A Case of Acute Hydrocephalus Occurring after Operative Treatment on Nontraumatic Cerebrospinal Fluid Rhinorrhea

Nontraumatic cerebrospinal fluid rhinorrhea is a very rare disease that comprises 3-4% of all CSF rhinorrhea cases. The principle treatment for CSF rhinorrhea is surgery because more conservative treatments usually fail. The authors executed extracranial repair of the fistula and sphenoid sinus obliteration with abdominal fat in a 33-year old male diagnosed with nontraumatic CSF rhinorrhea not accompanied by intracranial lesion. The CSF rhinorrhea stopped after the operation, but acute hydrocephalus developed on the postoperative second day, and a ventriculospinal shunt was performed. The authors report a case of acute hydrocephalus occurring after the repair of the CSF rhinorrhea, a development that, to our knowledge, has never been reported in the literature.

Nontraumatic Cerebrospinal Fluid Rhinorrhea(via the Middle Cranial Fossa and Sphenoid Sinus): A Case Report

We describe a rare case of nontraumatic normal pressure cerebrospinal fluid rhinorrhea. A 33-year-old male was admitted to our hospital due to continuous rhinorrhea but without a history of specific trauma. We performed various radiological evaluations, and on bone-window CT, detected severe bilateral extension of the sphenoid sinus into the greater wing. MRI and CT cisternography revealed that contrast media and cerebrospinal fluid had leaked from the middle cranial fossa to the sphenoid sinus. Transethmoidal sphenoid approach and sphenoid sinus fat obliteration was successfully performed by an otolaryngologist. On postoperative day 2, however, the patient's mental condition deteriorated and CT showed the development of acute obstructive hydrocephalus. Ventriculo-peritoneal shunt was then successfully performed and the patient was discharged. Nontraumatic normal pressure cerebrospinal fluid rhinorrhea involving leakage through the middle cranial fossa is very rare, this report discussed the etiological, anatomical and surgical considerations of this case.

Clinical Analysis of Sellar Tumors Treated via Transsphenoidal Route

Between January 1990 and August 1992 sixteen patients with sellar tumors underwent 16 transsphenoidal approaches at Kang-Nam Sacred Heart Hospital. Pathological diagnosis include 14 pituitary adenomas, of which six belonged to microadenomas and the remaining eight cases were classified as macroadenomas. Other pathologies were one craniopharyngioma and one sphenoid mucocele. Thirteen patients underwent TSA as the primary procedures and the remaining three patients were subjected to TSA as the secondary procedures to the primary treanscranial approaches. Of the 13 primary TSAs excellent or good results were achieved in 11 patients and the remaining two patients were subjected to the secondary transcranial approaches to achieve good results. Six patients with microadenomas achieved gross total or subtotal removal of their tumors in all cases(100%) however, satisfactory removal was achieved only in six macroadenoma cases(75%). There was neither surgical mortality nor major morbidity. Transient diabetes insipidus complicated in 6 patients(37.5%) and CSF rhinorrhea complicated in three cases*18.8%), which needed spinal drainage for three to ten days. Meningitis was complicated in one patient with CSF rhinorrhea(6.2%). This preliminary study agrees with that TSA is a safe and effective procedure even in macroadenoma cases.

Surgical Repair of Cerebrospinal Fluid Rhinorrhea: Report of Five Operative Cases

This report describes five cases of cerebrospinal fluid(CSF) rhinorrhea which were caused by head injury in four cases and developed after surgical removal of brain tumor in one case. Intrathecally-enhanced brain computerized tomography(CT) with metrizamide, in addition to isotope cisternography, was helpful in localization of the CSF leakage site. All five cases which could not be managed conservatively were successfully repaired by surgical means using biological fibrin glue.

A Case of Intracerebral Tension Pneumocephalus

Tension pneumocephalus is rare while pneumocephalus is relatively common. The former has sudden or insidious deterioration in neurologic symptoms and signs comparing to self-limited pneumocephalus. This report is of a 19 years old male with tension pneumocephalus in the right frontal lobe two underwent right frontal osteoplastic craniotomy.

Sphenoid Sinus Mucocele Complicated With Spontaneous CSF Rhinorrhea: Case Report

Mucocele is commonly found in frontal sinus. Mucocele of sphenoid sinus is rare and only 100 cases have been reported since Burg's description in 1889. Their etiology is still conjectural. These lesions are potentially more serious and are often misdiagnosed as pituitary tumor. The author experienced a case of sphenoid sinus mucocele develped headache, fever and CSF rhinorrhea. Plain skull, cisternography brain CT scan help the diagnosis of sphenoid sinus mucocele. A transnasal approach is considered best for case with extensive sphenoid sinus mucocele with bone destruction in the floor of sella turcica. The headache, fever and CSF rhinorrhea improved after surgery.