Unformatted text preview: Endoscopic Repair of CSF Endoscopic Repair of CSF Rhinorrhea
Michael Briscoe Jr., M.D.
Matthew Ryan, M.D.
Department of Otolaryngology
University of Texas Medical Branch
November 15, 2006 Overview
Pertinent HPI and PE
• First repair of CSF leak by Dandy in 1926 using frontal •
• craniotomy. (6080% success rate)
1948 first extracranial approach by Dohlman. (Naso
1952 Hirsch performed transnasal approach
First endoscopic CSF rhinorrhea repair in 1981 by Wigand. (~90% or better success rate)
– Less morbidity
– Standard of care for most cases of CSF rhinorrhea. Cerebrospinal Fluid
• CSF functions to give physical support and protection to the brain, transport waste products, and to regulate the chemical environment of the brain. CSF Physiology
• Total Volume of CSF in adult is 90150 ml.
• CSF is made in the choroid plexus and ependyma at rate of .35 ml/min (500 ml/d)
• Absorbed in arachnoid villi, total volume turned over 35 times per day. Flow rate of CSF
Flow rate of CSF
• Flow rates of CSF can be measured using MRI Flow of CSF
Flow of CSF
• Flows from Lateral •
• ventricle through foramen of Monroe to 3rd ventricle
Then through aqueduct of sylvius to 4th ventricle
Next, flows through foramina of Luschka and foramen of Magendie to enter subarachnoid space. Intracranial Pressure
• Normal ICP is 5 to 15 cm H2O while supine.
• Pressure changes with movement, time of day, cardiac cycle, and respiratory phase.
• Raised during REM sleep, sneezing, laughing and Valsalva. Disease processes involving CSF
Disease processes involving CSF
CSF leak CSF Leaks
• Occur due to dural tears or areas of dural weakness – Otorrhea due to temporal bone fractures
– Rhinorrhea due to anterior or central skull base dural defects Presenting Symptoms
• Recurrent Meningitis
Rhinorrhea, unilateral or bilateral
Obstructing nasal mass HPI
• Duration of symptoms
Onset of symptoms
Severity of rhinorrhea
Laterality of symptoms
Quantity and quality of rhinorrhea Important Questions
• Recent trauma
History of recurrent meningitis
Recent sinus surgery, endoscopic surgery, or neurosurgery
• History of hydrocephalus, or increased intracranial pressure Physical Exam
• Complete otolaryngologic exam
Cranial nerve testing
Weight and BMI
Testing for meningeal irritation such as nuchal rigidity, Kernig’s, or Brudzinsky Findings
• Clear rhinorrhea
Meningeal signs Differential Diagnosis
• Autonomic dysfunction
Temporal bone fracture with otorrhea Laboratory Testing Laboratory Testing • CSF has a slightly different composition than serum.
• Some proteins are found predominantly in CSF.
– Beta 2 transferrin
– Beta trace protein, 2nd most abundant protein found in CSF Laboratory Testing
• In active rhinorrhea, fluid sample can be collected at initial evaluation.
• With intermittent rhinorrhea, patient may collect sample at home.
• Need at least 0.5ml of fluid. Beta 2 transferrin
Beta 2 transferrin
• Produced by •
• neuraminidase activity in the brain, and found only in csf, perilymph, and aqueous humor
Electrophoresis used to detect
Most used laboratory test. 88% specif. Beta trace protein
Beta trace protein
• Synthesized in choroid plexus
• Concentration in CSF ~35 fold higher than •
Quick screening test
Not useful in patients with renal insufficiency or bacterial meningitis
Specificity 86100% Imaging
• CT scan
• MRI CT Scan
• CT scan is essential because of greater bone detail.
• Need high resolution scans, 3.0mm or less cuts.
• Axial with coronal reformats MRI
• For congenital cases of CSF rhinorrhea.
• Can identify areas of meningocele, or encephaloceles.
• Can identify areas were dura is thinned Additional Testing
• Intrathecal fluorescein aided nasal endoscopy
• Cisternography, Metrizamide CT cisternography or MRcisternography
• States of low flow or areas of thinning of dura can be identified Intrathecal Fluorescein
• 0.5 to 10% (2.550mg) •
• fluorescein injected into lumbar space prior to examination.
Mixed with 10 cc of CSF and slowly injected over 1020 minutes.
Nasal endoscopy yellow light filter on the endoscope and blue light filter on the light source “Off label” use IT Fluorescein complications
IT Fluorescein complications
• Transient pulmonary edema
Transient numbness in extremities
Severe side effects seen with doses of > 500mg Radioisotope Cisternography
• Radioactive contrast into intrathecal space.
• Pledgets placed in ant. cribriform, middle •
• meatus, and sphenoethmoidal recesses.
Left in place for several hours
Detects laterality of defect, but not precise location. Metrizamide CT Cistern
• Intrathecal contrast injected
• Great for sphenoid or frontal sinus leaks, and assessing meningoencephalocele
• Sensitivity 4896%
• Complications include:
– arachnoiditis Carrau et al.:Cerebrospinal Fluid Leaks; Laryngoscope 115 MR Cisternography
• No contrast material needed
Highlights CSF fistulas.
Identifies brain parenchyma and CSF in meningoencephaloceles.
• 8592% sensitivity, and 57100% specificity.
• Can detect intermittent or low flow leaks. Classification of CSF Rhinorrhea
Classification of CSF Rhinorrhea
• Etiology most important factor for success of surgery.
• Location most important factor for approach
• Size of defect Etiology
Etiology • Traumatic – 1030% of ant. Skull base fractures have associated rhinorrhea.
– Most common cause
– Blunt vs. penetrating • Congenital – encephalocele • Iatrogenic – Sinus surgery, transphenoidal hypophysectomy, other neuro. procedures • Tumor – Invasion through skull base • Spontaneous – Usually attributed to increased ICP Traumatic injury
• Rhinorrhea usually presents within first 48 hours.
• 70% close with conservative intervention
• Those not surgically closed, assoc. with 3040% risk of ascending meningitis Iatrogenic
• FESS – Lateral lamella of cribriform plate
– Posterior ethmoid near the roof of the antero
medial wall of sphenoid • Skull base surgery
• Transphenoidal hypophysectomy
– Disruption of sellar diaphragm • Craniofacial resections Congenital
• Relatively rare
Present as meningoencephalocele
Congenital skull base defect
Usually have large, funnelshaped defects
Normal ICP Sites of Lesions
Sites of Lesions
• Cribriform plate
• Reserved for blunt trauma with resolving CSF rhinorrhea
• May need lumbar drain
• HOB elevated, no nose blowing, or valsalva
• Acetazolamide to decrease CSF production when raised ICP is suspected Open Technique
• Reserved for large defects, multiple defects, or defects to lateral sphenoid sinus
• Posterior table of frontal sinus Endoscopic Technique
• Most causes of CSF rhinorrhea can be managed this way.
• Varying techniques, and graft material
• >90% first time success rate reported in literature Approaches to Anterior Cranium Approaches to Anterior Cranium base
• Paraseptal approach – cribriform plate, eth. – with or without sphenoidotomy • Transethmoidal sphenoid – With or without removal of basal lamella • Transethmoidalpterygoidalsphenoidal
– Lateral recess of sphenoid Paraseptal approach
Paraseptal approach Transethmoidal
• This type of approach was useful for defects located in the lateral wall of the sphenoid sinus. After performing an ethmoidosphenoidotomy and a wide middle antrostomy it was possible to identify the posterior wall of the maxillary sinus and the pterygoid base. The pterygopalatine artery was then coagulated and it was possible to drill the anterior wall of the sphenoid sinus and the pterygoid base until exposure of the lateral wall of the sphenoid sinus and the floor of middle cranial fossa Locatelli etal. Endoscopic endonasal apporaches; Operative Transethmoidalpterygoidal
sphenoidal Graft Material
• Cartilage and mucoperichondrium
Combined Middle turbinate harvest
Middle turbinate harvest Preparation of graft site
Preparation of graft site
• Recipient bed is prepared by removing several mm of mucosa to widely expose the defect.
• Mucosa must be thoroughly removed to increase adherence to site.
• Any encephaloceles must be reduced using bipolar at stalk to prevent intracranial hemorrhage. Closure Techniques
Gel foam packing Postoperative management
+/ lumbar drain
Avoid raising ICP
Repeat endoscopic evaluations Predictors of success
Predictors of success
• Good preoperative work up
Technically proficient with sinus surgery
Adequate exposure of defect
Choosing optimal procedure based on location
• Normal ICP Contraindications
• Presence of intracranial lesions
Comminuted fractures of the cranium base
Fractures of posterior wall of frontal sinus and lateral extensions of frontal sinus fractures. Complications
• Meningitis (0.3%)
Persistent leak (510%)
Pneumocephalus Intracranial hemorrhage or hematoma (0.3%)
• Frontal lobe abscess (0.9%)
• Anosmia (0.6%)
• Chronic headache (0.3%) Conclusions
• Nasal endoscopy
Beta2transferrin, or beta trace protein
Imaging to localize defect. HRCT for bony defects, MRI for herniations
Endoscopy provides 90% 1st time success, •
and up to 97% after 2nd look.
• Patients require close followup for resolution of rhinorrhea •
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- Fall '11
- Iatrogenesis, Sinusitis, CSF, Rhinorrhea, CSF rhinorrhea