CSF Rhinorrhoea: an Overview of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

Samir Joshi, Rahul Telang, Rahul Thakur

Department of Otorhinolaryngology & Head-Neck Surgery, B.J Medical College & Sassoon general hospital,

Pune-411001, Maharashtra. (INDIA)

ABSTRACT

A cerebrospinal fluid (CSF) rhinorrhoea occurs when there is communication between the subarachnoid space and the nasal cavity. CSF rhinorrhoea commonly occurs following head trauma (fronto-basal skullfractures), and as a result of intracranial surgery. The aim of our article was to emphasize the importance of endonasal endoscopic surgery using multilayer autograft technique.A total of 06 cases of CSF rhinorrhoea were treated. A retrospective study was undertaken to analyze the characteristics of 06 patients. After detailed otorhinolaryngoscopicexamination, DNE and radiological evaluation by CT and MRI, all underwent endonasal endoscopic surgery. This article reviews the causes, diagnosis and treatment of CSF leakage of cases done with a 0 degree 4mm sinoscope using fascia lata septal cartilage and fat as a graft material. The defects as large as 1.5 cm could be safely treated with this technique. The overall success rate of endoscopic repair for CSF rhinorrhoea has been 100%.

Keywords: CSF rhinorrhoea, endoscopic repair,cerebrospinal fluid,multilayer autograft.

INTRODUCTION

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

Surgical management of patients with head trauma requires highly skilled personnel and the success depends on anumber of factors including etiology, intracranial pressure,concomitant injuries, patient age and the possibility of anInterdisciplinary procedure. The other critical factor is impaired tissue repair, which may be due to lack of proper closure, inadequate support of weak healing tissues, and poor healing of tissue owing to infection, metabolic disorders and other chronic disease.CSF leak is an escape of the fluid that surrounds the brain and spinal cord, from the cavities within the brain or central canal in the spinal cord. A CSF rhinorrhoea occurs when there is a communication between the subarachnoid space and the nasal cavity and discharge of CSF from the nose. A spinal fluid leak from the intracranial space to the nasal respiratory tract is potentially very serious because of the risk of an ascending infection which could produce fulminant meningitis1. Endoscopic repair of these defects is widely practiced, and has led to 90% success rate after first repair2. The first repair of CSF leak was performed by Dandy in 1926 using a frontal craniotomy. Although traumatic leakage of CSF is more common, the first published case of CSF rhinorrhoea was a non traumatic high pressure type due to hydrocephalus reported by Miller in 18263, followed by reports by King in 18344..

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

ETIOLOGY

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

The etiologic classification of CSF leak was developed by Ommaya et al5He classified CSF rhinorrhoea into traumatic and nontraumatic, subdividing the latter into nontraumatic with normal pressure and nontraumatic withincreased CSF pressure. Fain et al6 classified in five types. Type I: involves only the anterior wall of the frontalsinus. Type II: involves the face (craniofacial disjunctionof the Lefort II type or crush face) and extend upward tothe cranial base and, in occurrence, to the anterior wall ofthe frontal sinus, because of the facial retrusion. Type III:involves frontal part of the skull and extend down to thecranial base.TypeIV: is a combination of typesII and III.Type V: involves only ethmoidal or sphenoidal bones. The most common locations for injury are the lateral lamella of the cribriform plate and the posterior ethmoids near the anteromedial wall of the Sphenoid. Traumatic CSF leaks have no relationship with age or sex, whereas the nontraumatic variety affects adults mainly over 30 and female twice as common as male.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

AIMS AND OBJECTIVES

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

To emphasize the importance of endonasal endoscopic approach by using multilayer autograft technique i.e.: septal cartilage, fascia lata and fat and to discuss the cause and treatment of persistent CSF rhinorrhoea.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

MATERIAL AND METHODS

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

A total of six cases of CSF rhinorrhoea of rhinologic origin were treated (1 year).

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

A retrospective study was undertaken to analyze the characteristics of six patients with CSF rhinorrhoea. Cases were selected from the patients coming to ENT OPD of our institute. After detailed otorhinolaryngoscopic examination, Diagnostic Nasal Endoscopy and radiological evaluation by CT and MRI, all underwent endonasal endoscopic surgery using multilayer autograft technique

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

SELECTION CRITERIA

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

Cases were selected from patients coming to ENT OPD with defect less than 1.5 cm.

Cases with CSF rhinorrhoea of rhinologic origin.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

EXCLUSION CRITERIA

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

Cases with CSF rhinorrhoea with defect size more than 1.5 cm.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CLINICAL PICTURE

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

In most traumatic cases (>50%), rhinorrhoea stops within one week and in most within six months. Out of the six patients presented to OPDfour patients had complaints ofRecurrent meningitis more than two episodes, Recurrent headache,fever, malaise, giddiness, vomiting. Two patients presented with trauma along with complaint of watery discharge from single nare since then.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

DIAGNOSIS

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

Accurate identification of the site of CSF leakage is necessary for a successful surgical repair. Diagnosis through nasal endoscopy can give an exact diagnosis in some cases. Howeverthe dimensions,boney anatomy of the surrounding area cannot be assessed on a simple diagnostic nasal endoscopy. Fluid leaking from the nose if placed on absorbentfilter paper may result in the double-ring sign, which isa central circle of blood and an outer ring of CSF. Beta-2 transferrin assay is more specificFor CSF, but incase of associated orbital injuries this can be unreliable due to the presence of beta-2 transferrin in vitreous humour7. Beta-2 transferrin is a carbohydrate-free(desialated) isoform of transferrin, which is almost exclusively found in the CSF8.Beta-2 transferrin has a sensitivity of near 100% and a specificity of about 95% 9.. Glucose detection using Glucostix test strips is not recommended as a confirmatory test due to its lack of specificity and sensitivity 10.

Intrathecal injection of Fluorescein dye is utilized by some surgeons for identifying the area of a CSF leak.Injection involving a solution of 0.5%-10% Fluorescein dye is injected andthe patient is then examined roughly 30 minutes to an hour later with an endoscope. High resolution, thin section axial and Coronal cranial and facial CT includes all of the paranasal sinuses and petrous temporal bones in the scans is helpful in defect localization. CT Cisternography: the use of less irritating water soluble positive contrast media such as metrizamide combined with CT scanning and suitableimage reconstruction can often be useful in pinpointing leak location. CT Cisternography cannot be undertaken in presence of meningitis. In such cases,MRI with CT is done.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

TREATMENT

MEDICAL

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

The use of antibiotics in the treatment of CSF rhinorrhoea remains controversial. The reason for their use is to prevent intracranial infection (meningitis). Villalobos et al published a meta-analysis in 1998 that reviewed 12 studies and 1241 patients with CSF leaks. 719 patients were treated with antibiotics while 522 patients were not treated with antibiotics. They found that patients were 1.34 times more likelytodevelop meningitis without the use of antibiotics when a basilar skull fracture had resulted in a CSF leak. With all causes of CSF leak, patients were only 1.10 times more likely to develop meningitis without the use of antibiotics. For this reason, they recommended not using antibiotics when CSF leaks are present11.However conservative management with stool softeners, bed rest, head elevation, avoid straining, avoiding lifting of heavy objects can be considered.

SURGICAL

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

The surgical management of CSF rhinorrhoea is categorized into open and closed approach.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

TECHNIQUE:

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

All the patients gave written informed consent; theyunderwent Endonasal endoscopic surgery using multilayer autograft techniqueunder General anesthesia.

Antibiotics along with IVmannitol, Antihistaminics, Stool softeners like syrup cremaffin, Cough suppressants were administered to the patients.

Merocel nasal packwas kept for 48 hrs.Strict bed rest was given to pt for 2 weeks.

Head elevation was given at 30 degrees.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

RESULTS

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

Between 2010 and 2011, seven patients visited to the ENT OPD of our institute. Out of which six underwent endoscopic repair of CSF rhinorrhoea at our institution. One patient was referred to Neurosurgeon for open repair as the defect was more than 1.5 cm.Age of the patients ranged from 09-40 yrs. With male predominance. The durations of symptoms ranged from 2 months to 10 months. Post traumatic leak was present in five patients, spontaneous leak was seen in one patient.Four patients had defect in Anterior ethmoids. One each in posterior ethmoids and sphenoid respectively. Size of the defect ranged from 0.5 cm to 1.5 cm.Repair was successful in 100 %patients; Meanfollow-up was 6 months with a range of 2 months to 12 months. Our results are comparable to thatreported in literature (Table1).

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

DISCUSSION

Most neurosurgeons prefer the intracranial approach. Exposure of the skull base and the necessity of brain retraction during intracranial procedures are associated with a significant risk of anosmia, postoperative intracerebral hemorrhage, and brain edema. Multiple approaches to the management of CSF rhinorrhoea can be successful. Anendoscopic repair results in resolution of CSF rhinorrhoeain majority of the cases.Endoscopicrepair provides best exposure of the sphenoid, parasellar, and posterior ethmoidal regions and offer excellent visualization of fistulas in the posterior wall of the frontal sinus, the cribriform plate, and the fovea ethmoidalis.Transnasal endoscopic surgery minimizes intranasal trauma and preserves the bony framework supporting the frontal recess and other critical areas. Patients with spontaneous CSF rhinorrhoea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases. In our study lumbar drain was not used as advocated by neurosurgeon of our institute. Fibrin glue was not used as it has high cost and patients were non affording.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CONCLUSION

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

The success rate of repair was 100 %. We conclude that it is reasonable in majority of cases to proceed with endoscopic approach rather than going for externalapproach. Endonasal approach is less morbid compared with external approach. Endoscopic surgery gives better visualization. AsRevisionsurgery can be done with ease. Healing can be observed in follow up with endoscopic evaluation. Patient undergoing primary endoscopic repair have less likely chance of developing anosmia or other neurodeficit as compared to patients undergoing open surgery.

We emphasize the importance of multilayer auto graft material as CSF rhinorrhoea is notorious for graft displacement.

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair

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CSF Rhinorrhoea: An Overview Of Endoscopic Repair

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CSF Rhinorrhoea: An Overview Of Endoscopic Repair

CSF Rhinorrhoea: An Overview Of Endoscopic Repair