Pediatric cerebrospinal fluid rhinorrhea caused by low flow vascular anomaly of the temporal bone: A case series.

OBJECTIVE: Atraumatic cerebrospinal fluid (CSF) rhinorrhea is uncommon in children and necessitates a multi-disciplinary evaluation for an etiology. Underlying osseous abnormality due to extensive or multifocal low flow vascular anomaly should be considered as a potential cause of spontaneous CSF leak. Treatment of multifocal low flow vascular anomalies may include medical and surgical approaches. In this series, we seek to determine the presenting signs and symptoms and medical and surgical treatment options for multifocal or extensive low flow vascular anomalies. METHODS: A retrospective case series at a quaternary care children's hospital was compiled. All children with CSF rhinorrhea diagnosed and treated for multifocal low flow vascular anomalies at our institution were included. A total of four patients were identified. RESULTS: All four patients had delay in initial diagnosis of underlying cause of meningitis and CSF rhinorrhea. Average age at diagnosis of multifocal low flow vascular anomaly was 7 years. This was on average 4 years after initial presentation for medical attention. Treatment approach was multidisciplinary and included medical management with sirolimus and bisphosphonates as well as surgical approaches to the skull base (lateral and anterior) to prevent CSF egress. CONCLUSION: Consideration of multifocal low flow vascular anomaly should be included in any pediatric patient presenting with CSF rhinorrhea.

Perioperative care of the vascular anomaly patient.

Patients with vascular anomalies present specific and unique challenges to providers of their postoperative care. Vascular anomalies can range from localized solitary lesions to diffuse lesions with vessel malformations and associated soft tissue, muscle, organ, and bone involvement. Perioperative issues for these patients can be complicated and include coagulopathies requiring anticoagulation, the need for postoperative surgical drains and specialized wound care, and the use of compression garments to maintain the desired postoperative result. This article will address these specific concerns for patients with vascular anomalies in order to create a framework for consistent and appropriate perioperative care.

Coordination of multiple services for a patient with severe lymphedema of the right lower extremity.

Surgical resection of the right lower extremity in an adult with severe lymph-edema of the extremity required intensive coordination of multiple services and specialists because of the medical and surgical complexity of the patient's condition, massive limb size, and surgical location in a children's hospital. Early and prolonged planning was necessary to anticipate problems and provide optimal care. The patient had a successful surgical outcome, improvement in medical comorbid conditions postoperatively, and improvement in the quality of life upon discharge. This coordinated effort will be used in the future as a template for patients with complex conditions whose care requires lengthy planning and involves multiple services and specialists.