The first comprehensive description of CSF leak in a child with hydrocephalus was given by a surgeon, Charles Miller, in 1826.' 63 (2):197-201. The use of image-guidance systems is strongly encouraged for skull base procedures. Incus and head of malleus being removed , to reach anteriormost Advantages of the intracranial approach include the ability to inspect the adjacent cerebral cortex, directly visualize the dural defect and seal a leak in the presence of increased ICP with a larger graft. The postoperative temporal bone. Reinforced local mucosa flaps or pedicledosteo-osteo-mucoperiosteal or chondro-mucoperi­chondrial flaps were used nine times. It’s combined with mini middle cranial fossa approach [5] to Ensuring that mucosa is not retained within the defect is key to prevent future mucocele formation. 1952. temporal lobe retraction. 1926. In 21 of these 29 patients who underwent second repair surgery at Mayo, the mean interval between primary surgery and first recurrence could be determined. All other repairs that were followed by meningitis, pneumocephalus, or recurrent CSF rhinorrhea were classified as unsuccessful with recurrence (Tables I and I I ). Rhinosurgical origin: A paranasal sinus or other exter­nal or endonasal extradural procedure (such as orbital decompression). Such a graft placement also facilitates The history of surgical therapy for CSF rhinorrhea began with the first successful intracranial repair by the American surgeon Walter Dandy in 1929.3 It took another 19 years until the first extracranial repair was performed by the Swedish physician, Gösta Dohlman.4 He repaired a leak of the roof of the ethmoid via a nasoorbital incision. The first layer which was temporalis fascia, neurological and combined. leaks that present as nasal leaks but having an otologic origin. The ethmoidal cells are then entered in the area of the lacrimal fossa, and the anterior two thirds of the lamina are removed. It has also been noted to be characterized by unilateral discharge. In such situations, as the tympanic membrane is intact( unless An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus. After revision CSF repair surgery and placement of a right ventriculoperitoneal shunt for increased CSF pressure. The sphenoid sinus ostium is identified and opened first with a small curette or a beaded probe. Figure 14A and B The complication rate of all procedures that required a transcra­nial approach was higher (12.9%) than that of all extracra­nial operations (3.2%) (p = 0.063). through the nose, a normal CT PNS (prior to nasal exploration), The frontal sinus outflow tract must be carefully preserved in order to prevent mucocele formation in the long term. It covered the defect in bone and reached beyond the defect This artery needs to be ligated to increase exposure. such as free autologous grafts or reinforced flaps. building over the years leading to remodelling of weak bones finally Spontaneous CSF leaks, according to the scheme developed by Ommaya, are those of nontraumatic etiologies. Nishihira S, McCaffrey T. The use of fibrin glue for the repair of experimental CSF rhinorrhea. Successful closure of cerebrospinal fluid rhinorrhea by endonasal surgery. Hosemann W. Nitsche N, Rettinger G. et al. Patient Selection Cases of CSF rhinorrhea of otologic origin were not analyzed. The remaining failures followed orbital decom­pression surgery. 1994. © 2020 Rector and Visitors of the University of Virginia. defect. Therefore, not surprisingly, his notion that the release of cerebro­spinal fluid (CSF) through the nose was a physiologic process carried into the Renaissance and was not dispelled until the seventeenth century. This can cause meningitis or a brain abscess which can be life-threatening. Complications of trans-sphenoidal surgery. Figure 2. There are a multitude of potential donor sites if bone is required for the repair. Similar presentation may of the middle ear and Eustachian tube may also be required, especially mater and the defect in temporal bone in layers. unless an otologic source is certain, the scan should cover all 3 Post-operative CT scan showed bone graft in place (Figure 16A and B) and post-operative otoendoscopy showed intact tympanic membrane (Figure 16C). This in­terval was 50.8 months (range: l day-28 years). [Medline]. complaints of giddiness though he was having mild hearing loss on The transmastoid approach provides J Neurosurg. Post operative otoendoscopy examination showing intact Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons 3/13 cases). an osseous defect and a CSF pressure gradient that is continuously or intermittently greater than Diagnosis is based on a high index of suspicion, complete clinical evaluation, and radiological [Medline]. defect in tegmen antri and tegmen mastoideum near its lateral Defects in the posterior table of the frontal sinus may be approached externally via a coronal incision and osteoplastic flap. 1997. Intradural graft placement is fascia which was again tucked in around the defect from mastoid side The use of nasal mucosa advancement flaps alone has been dis­carded. The average follow-up was 109 months, with a range of I month to 273 months. Palm Desert , California , April 25-26, 1999 Address correspondence and reprint requests to Dr. David A. Sherris, Department of Otorhinolaryngology, Mayo Clinic, 200 First Street SW , Rochester , MN 55905, (12.9% versus 3.2%). generally preferred in such cases, as it guarantees repair of meninges CSF rhinorrhoea may not always be due to anterior cranial fossa and 20.7% (17/82) a transcranial approach. All but one of these complications resulted from revision repairs, and an intracranial or combined ap­proach had been used in five of these eight cases. Laryngoscope. } else { When preoperative localization attempts fail to reveal the site of a leak, intracranial approach with blind repair has been successful. Proud GO. jQuery( "" ).prependTo( x[i] ); then finally covered with temporalis fascia again and then covered Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of MedicineDisclosure: Nothing to disclose. be detected with congenital disorders, such as Mondini anomaly, However, this finding was not statistically significant. [Full Text]. Precisely 0.1 mL of 10% fluorescein is mixed with 10 mL of CSF or bacteriostatic saline. There are other causes for these problems, as well as for watery drainage from the nose, so it is important to see your doctor to help determine the cause of your symptoms. This can be a chronic condition but with the potential complications and possible loss of quality of life, you should explore it further. 1992 Nov. 77(5):737-9. Reinforced nasal mucosa flaps. If questionnaires were not answered, patients were interviewed by telephone. Similarly, a literature review by Ratilal et al did not find evidence for the usefulness of antibiotic prophylaxis in patients with basilar skull fractures, with or without indication of CSF leakage. We feel that the present data encourage the use of cartilage or bone in order to stabilize larger defects. A large defect is noted, and the meningocele has been resected. Figure 14C taken for each case depending on different factors. Seven of these patients with high pressure leaks were treated with the placement of a ventriculoperitoneal shunt before or during their CSF repair. 4). Once the underlay graft has been placed and secured with fibrin glue, autologous fat can be placed to further assist with closure of the defect. Figure 3. [Medline]. dataTOCHeader = x[i].innerText; Followed by temporalis fascia graft and tissue glue. The optic nerve lies 5 mm posterior to the posterior ethmoidal artery. The craniotomy was performed with a medium sized cutting burr first and small sized The use of prophylactic antibiotics in patients incurring skull base injuries during endoscopic sinus surgery has not been studied in a randomized controlled fashion. However, the investigators found the studies to be flawed by biases, determining that no conclusion could be reached on the effectiveness of prophylactic antibiotics in cases of basilar skull fracture. Depending on the size of the leak, patients may note a continual salty taste and a sense of drainage in the throat or watery drainage from the nose. 1993 Apr. However, in most cases, to cure cerebrospinal fluid rhinorrhea, surgery will be necessary. If a stronger outermost later is needed, such as in clival defects, a temporalis fascia or tensor fascia lata graft can provide the necessary support and has been used with acceptable success. This combined approach failed. However, the authors believe that given the previously published rates of ascending meningitis in untreated CSF leaks, the administration of perioperative intravenous antibiotics is warranted. Not all cases of postoperative meningitis are due to the aforementioned bacteria. Successful cases were only included if postoperative follow-up was longer than 12 months. Final layer of fibrin glue to seal all layers. A cause of recurrent meningitis in a child: cochlear dysplasia. The approach begins by performing a complete ethmoidectomy. Failure rates for this approach are 40% for the first attempt and 10% overall. Defect size is an important factor that should be taken into account when choosing the number of layers used to repair the CSF leak. In: Gulya AJ, editor. The principle is that the injuries), the mastoid may need to be obliterated with fat. Six of the eight patients with complications required a revision surgery or an additional procedure, such as abscess drainage or decompression of a tension pneumocephalus. Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. endoscopic sinus surgery changes with CSF leak from nasopharynx Cappabianca P, Cavallo LM, Esposito F, et al. Free graft with fibrin glue added: free graft as de-scribed in (I) fixed with fibrin glue. The endonasal ap­proach was the single most successful approach, with 14.3% recurrence rate. verify here. donor site morbidity. If you log out, you will be required to enter your username and password the next time you visit. Outcome Spontaneous cerebrospinal fluid rhinorrhea. (Defect measured approximately 7mm.). Stammberger H. Greistorfer K, Wolf G. et al. The incus and head of malleus removed gently