Facial Plast Surg 2009; 25(1): 029-037
DOI: 10.1055/s-0028-1112229
© Thieme Medical Publishers

Endoscopic Management of Cerebrospinal Fluid Leaks

J. Drew Sanderson1 , Stilianos E. Kountakis2 , K. Christopher McMains1
  • 1University of Texas Health Science Center at San Antonio, San Antonio, Texas
  • 2Medical College of Georgia, Augusta, Georgia
Further Information

Publication History

Publication Date:
10 February 2009 (online)

ABSTRACT

Cerebrospinal fluid (CSF) rhinorrhea is an uncommon but important medical condition. It can result from trauma, intracranial hypertension, or be idiopathic in origin. If left untreated, significant sequelae can result including infectious meningitis. Beta-2 transferrin is a sensitive and specific protein marker for CSF. Various radiographic modalities have been used to localize defects, including computed tomography (CT), magnetic resonance imaging, and CT cisternography. In recent years, surgical management of this condition has evolved significantly, primarily being performed endoscopically. Reconstruction can be performed with fat, free mucosal, or fascial grafts, or with vascularized flaps. The endoscopic surgeon should have a thorough understanding of the pathophysiology and diagnosis of CSF rhinorrhea as well as several surgical options in his or her armamentarium available to treat the patient suffering from CSF rhinorrhea.

REFERENCES

  • 1 Citardi M. Cerebrospinal fluid rhinorrhea. In: Cummings C Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia, PA; Elsevier 2005: 1276-1289
  • 2 Dandy W D. Pneumocephalus (intracranial pneumocele or aerocele).  Arch Surg. 1926;  12 949-982
  • 3 Dohlman G. Spontaneous cerebrospinal rhinorrhea.  Acta Otolaryngol Suppl. 1948;  67 20-23
  • 4 Chandler J R. Traumatic cerebrospinal fluid leakage.  Otolaryngol Clin North Am. 1983;  16 623-632
  • 5 Hirsch O. Successful closure of cerebrospinal fluid rhinorrhea by endonasal surgery.  AMA Arch Otolaryngol. 1952;  56 1-12
  • 6 Vrabec D P, Hallberg O E. Cerebrospinal fluid rhinorrhea.  Arch Otolaryngol. 1964;  80 218-229
  • 7 Ray B S, Bergland R M. Cerebrospinal fluid fistula: clinical aspects, techniques of localization, and methods of closure.  J Neurosurg. 1969;  30 399-405
  • 8 Park J L, Strolzow V V, Friedman W H. Current management of cerebrospinal fluid rhinorrhea.  Laryngoscope. 1983;  93 1294-1300
  • 9 Wigand M E. Transnasal ethmoidectomy under endoscopic control.  Rhinology. 1981;  19 7-15
  • 10 Locatelli D, Rampa F, Acchiardi I. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience.  Neurosurgery. 2006;  58 246-256
  • 11 Wormald P J, McDonogh M. The bath-plug closure of anterior skull base cerebrospinal fluid leaks.  Am J Rhinol. 2003;  17 299-305
  • 12 Mirza S, Thaper L, McClelland L. Sinonasal cerebrospinal fluid leaks: management of 97 patients over 10 years.  Laryngoscope. 2005;  115 1774-1777
  • 13 Hegazy H M, Carrau R L, Snyderman C H. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.  Laryngoscope. 2000;  110 1166-1172
  • 14 Kirtane M V, Gautham K, Upadhyaya S R. Endoscopic CSF rhinorrhea closure: our experience in 267 cases.  Otolaryngol Head Neck Surg. 2005;  132 208-212
  • 15 Schlosser R J, Bolger W E. Endoscopic management of cerebrospinal fluid rhinorrhea.  Otolaryngol Clin North Am. 2006;  39 523-538
  • 16 Bernal-Sprekelsen M, Eleda-Vazques C, Carrau R L. Ascending meningitis secondary to traumatic cerebrospinal fluid leaks.  Am J Rhinol. 2000;  14 257-259
  • 17 Friedman J A, Ebersold M J, Quast L M. Post-traumatic cerebrospinal fluid leakage.  World J Surg. 2001;  25 1062-1066
  • 18 Daudia A, Biswas D, Jones N S. Risk of meningitis with cerebrospinal fluid rhinorrhea.  Ann Otol Rhinol Laryngol. 2007;  116 902-905
  • 19 McMains K C, Gross C W, Kountakis S E. Endoscopic management of cerebrospinal fluid rhinorrhea.  Laryngoscope. 2004;  114 1833-1837
  • 20 Schlosser R J, Wilensky E M, Grady M S. Cerebrospinal fluid pressure monitoring after repair of cerebrospinal fluid leaks.  Otolaryngol Head Neck Surg. 2004;  130 443-448
  • 21 Schlosser R J, Wilensky E M, Grady M S. Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks.  Am J Rhinol. 2003;  17 191-195
  • 22 Wise S K, Schlosser R J. Evaluation of spontaneous nasal cerebrospinal fluid leaks.  Curr Opin Otolaryngol Head Neck Surg. 2007;  15 28-34
  • 23 Woodworth B A, Schlosser R J, Faust R A. Evolutions in management of congenital intranasal skull base defects.  Arch Otolaryngol Head Neck Surg. 2004;  130 1283-1288
  • 24 Zweig J L, Carrau R L, Celin S E. Endoscopic repair of acquired encephaloceles, meningoceles, and meningo-encephaloceles: predictors of success.  Skull Base. 2002;  12 133-139
  • 25 Neligan P C, Mulholland S, Irish J et al.. Flap selection in cranial base reconstruction.  Plast Reconstr Surg. 1996;  98 1159-1166
  • 26 Smith J E, Ducic Y. The versatile extended pericranial flap for closure of skull base defects.  Otolaryngol Head Neck Surg. 2004;  130 704-711
  • 27 Snyderman C H, Janecka I P, Sekhar L N et al.. Anterior cranial base reconstruction: role of galeal and pericranial flaps.  Laryngoscope. 1990;  100 607-614
  • 28 Leong J L, Citardi M J, Batra P S. Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms.  Am J Rhinol. 2006;  20 476-482
  • 29 Germani R M, Vivero R, Herzallah I R et al.. Endoscopic reconstruction of large anterior skull base defects using acellular dermal allograft.  Am J Rhinol. 2007;  21 615-618
  • 30 Hadad G, Bassagasteguy L, Carrau R et al.. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap.  Laryngoscope. 2006;  116 1882-1886
  • 31 Bateman N, Jones N S. Rhinorrhea feigning cerebrospinal fluid leak: nine illustrative cases.  J Laryngol Otol. 2000;  114 462-464
  • 32 Meurman O H, Irjala K, Suonpaa J et al.. A new method for the identification of cerebrospinal fluid leakage.  Acta Otolaryngol. 1979;  87 366-369
  • 33 Warneck A, Averbeck T, Wurster U et al.. Diagnostic relevance of beta2-transferrin for the detection of CSF fistulas.  Arch Otolaryngol Head Neck Surg. 2004;  130 1178-1184
  • 34 Arrer E, Meco C, Oberascher G et al.. Beta-trace protein as a marker for cerebrospinal fluid rhinorrhea.  Clin Chem. 2002;  48(6 Pt 1) 939-941
  • 35 Reisinger P W, Hochstrasser K. The diagnosis of CSF fistulae on the basis of detection of beta 2-transferrin by polyacrylamide gel electrophoresis and immunoblotting.  J Clin Chem Clin Biochem. 1989;  27 169-172
  • 36 Hegarty S E, Millar J S. MRI in the localization of CSF fistulae: is it of any value?.  Clin Radiol. 1997;  52 768-770
  • 37 Jinkins J R, Rudwan M, Krumina G et al.. Intrathecal gadolinium-enhanced MR cisternography in the evaluation of clinically suspected cerebrospinal fluid rhinorrhea in humans: early experience.  Radiology. 2002;  222 555-559
  • 38 Crow H J, Keogh C, Northfield D W. The localization of cerebrospinal fluid fistulae.  Lancet. 1956;  271 325-327
  • 39 Marshall A N, Jones N S, Robertson I J. An algorithm for the management of CSF rhinorrhea illustrated by 36 cases.  Rhinology. 1999;  37 182-185
  • 40 Zapalac J S, Marple B F, Schwade N D. Skull base cerebrospinal fluid fistulas: a comprehensive diagnostic algorithm.  Otolaryngol Head Neck Surg. 2002;  126 669-676
  • 41 Castelnuovo P, Mauri S, Locatelli D et al.. Endoscopic repair of cerebrospinal fluid rhinorrhea: learning from our failures.  Am J Rhinol. 2001;  15 333-342
  • 42 Casiano R R, Jassir D. Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?.  Otolaryngol Head Neck Surg. 1999;  121 745-750
  • 43 Kirchner F R, Proud G O. Method for the identification of CSF fluid, rhinorrhea and otorrhea.  Laryngoscope. 1960;  70 921-930
  • 44 Moseley J I, Carton C A, Stern W E. Spectrum of complications in the use of intrathecal fluorescein.  J Neurosurg. 1978;  48 765-767
  • 45 Keerl R, Weber R K, Draf W et al.. Use of sodium fluorescein solution for detection of cerebrospinal fluid fistulas: an analysis of 420 administrations and reported complications in Europe and the United States.  Laryngoscope. 2004;  114 266-272
  • 46 Martin T J, Loehrl T A. Endoscopic CSF leak repair.  Curr Opin Otolaryngol Head Neck Surg. 2007;  15 35-59
  • 47 Bolger W E, Osenbach R. Endoscopic transpterygoid approach to the lateral sphenoid recess.  Ear Nose Throat J. 1999;  78 36-46
  • 48 Bachmann-Harildstad G, Kloster R, Bajic R. Transpterygoid transphenoid approach to the lateral extension of the sphenoid sinus to repair a spontaneous CSF leak.  Skull Base. 2006;  16 207-212
  • 49 Pasquini E, Sciarretta V, Farneti G et al.. Endoscopic treatment of encephalocele of the lateral wall of the sphenoid sinus.  Minim Invasive Neurosurg. 2004;  47 209-213
  • 50 Kuhn F A. An integrated approach to frontal sinus surgery.  Otolaryngol Clin North Am. 2006;  39 437-461
  • 51 Gross W E, Gross C W, Becker D et al.. Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration.  Otolaryngol Head Neck Surg. 1995;  113 427-434
  • 52 Gross C W, Zachmann G C, Becker D G et al.. Follow-up of University of Virginia experience with the modified Lothrop procedure.  Am J Rhinol. 1997;  11 49-54
  • 53 Friedman M, Venkatesan T K, Caldarelli D D. Composite mucochondral flap for repair of cerebrospinal fluid leaks.  Head Neck. 1995;  17 414-418
  • 54 Gassner H G, Ponikau J U, Sherris D A, Kern E B. CSF rhinorrhea: 95 consecutive surgical cases with long term follow-up at the Mayo Clinic.  Am J Rhinol. 1999;  13 439-447
  • 55 Schmerber S, Righini C, Lavielle J P et al.. Endonasal endoscopic closure of cerebrospinal fluid rhinorrhea.  Skull Base. 2001;  11 47-57
  • 56 Wormald P J, McDonogh M. “Bath-plug” technique for the endoscopic management of cerebrospinal fluid leaks.  J Laryngol Otol. 1997;  111 1042-1046
  • 57 Bolger W E, McLaughlin K. Cranial bone grafts in cerebrospinal fluid leak and encephalocele repair: a preliminary report.  Am J Rhinol. 2003;  17 153-158
  • 58 Eloy J A, Fatterpekar G M, Bederson J B et al.. Intracranial mucocele: an unusual complication of cerebrospinal fluid leakage repair with middle turbinate mucosal graft.  Otolaryngol Head Neck Surg. 2007;  137 350-352
  • 59 Wang L, Kim J, Heliman C B. Intracranial mucocele as a complication of endoscopic repair of cerebrospinal fluid rhinorrhea: case report.  Neurosurgery. 1999;  45 1243-1245
  • 60 Brodie H A. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae.  Arch Otolaryngol Head Neck Surg. 1997;  123 749-752
  • 61 Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures.  Cochrane Database Syst Rev. 2006;  25 CD004884

Stilianos E KountakisM.D. Ph.D. 

Medical College of Georgia, 1120 15th Street

Augusta, GA 30912

Email: skountakis@mcg.edu

    >