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CSF-rhinorrhea-slides-061111 - Endoscopic Repair of CSF...

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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 Galveston, TX November 15, 2006 Overview Overview • • • • • • • History CSF physiology Pertinent HPI and PE Diagnostic Testing Classification Treatment Conclusion History History • First repair of CSF leak by Dandy in 1926 using frontal • • • craniotomy. (60­80% success rate) 1948 first extracranial approach by Dohlman. (Naso­ orbital incision) 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 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 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 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 • • • Hydrocephalus Meningitis CSF leak CSF Leaks 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 Presenting Symptoms • • • • • Recurrent Meningitis Intracranial abscess Rhinorrhea, unilateral or bilateral Headache Obstructing nasal mass HPI HPI • • • • • • Duration of symptoms Onset of symptoms Associated symptoms Severity of rhinorrhea Laterality of symptoms Quantity and quality of rhinorrhea Important Questions Important Questions • • • Recent trauma History of recurrent meningitis Recent sinus surgery, endoscopic surgery, or neurosurgery • History of hydrocephalus, or increased intracranial pressure Physical Exam Physical Exam • • • • • Complete otolaryngologic exam Cranial nerve testing Nasal endoscopy Weight and BMI Testing for meningeal irritation such as nuchal rigidity, Kernig’s, or Brudzinsky Findings Findings • • • • Clear rhinorrhea Bony deformity Intranasal mass Meningeal signs Differential Diagnosis Differential Diagnosis • • • • • Autonomic dysfunction Atrophic Rhinitis Allergic Rhinitis Sinonasal Polyposis 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 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 • • • • plasma. Quick screening test Not useful in patients with renal insufficiency or bacterial meningitis Sensitivity 78­100% Specificity 86­100% Imaging Imaging • CT scan • MRI CT Scan 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 MRI • For congenital cases of CSF rhinorrhea. • Can identify areas of meningocele, or encephaloceles. • Can identify areas were dura is thinned Additional Testing 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 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 Seizure Transient numbness in extremities Death Severe side effects seen with doses of > 500mg Radioisotope Cisternography 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: – Headache – Nausea – arachnoiditis Carrau et al.:Cerebrospinal Fluid Leaks; Laryngoscope 115 MR Cisternography 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 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 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 Congenital • • • • • • Relatively rare Present as meningoencephalocele Congenital hydrocephalus Congenital skull base defect Usually have large, funnel­shaped defects Normal ICP Sites of Lesions Sites of Lesions • • • • • Cribriform plate Ethmoid Frontal Sphenoid Multiple Management Management • • • Conservative Open Endoscopic Conservative Conservative • 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 Open Technique • Reserved for large defects, multiple defects, or defects to lateral sphenoid sinus • Posterior table of frontal sinus Endoscopic Technique 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 Transethmoidal Transethmoidal­sphenoidal­ pterygoidal • 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 Transethmoidal­pterygoidal­ sphenoidal Graft Material Graft Material • • • • • • • Cartilage and mucoperichondrium Middle turbinate Conchal cartilage Abdominal fat Mucosa Fascia 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 Closure Techniques • • • • Overlay Combined Obliteration Gel foam packing Post­operative management Post­operative management • • • • • Bedrest Stool softeners +/­ 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 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 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 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 • • • • • • • • • • • • • • Resources Resources Hegazy, HM et al. Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: a Meta­analysis. Laryngoscope 2000;110:1166­1172 Schlosser RJ, Bolger WE. Nasal Cerebrospinal Fluid Leaks: Critical Review and Surgical Considerations. Laryngoscope 2004;114:255­265 Locatelli D, et al. Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks: Nine Year Experience. Operative Neurosurgery 2006;58:246­57 Lidstrom DR, et al. Management of Cerebrospinal Fluid Rhinorrhea: The Medical College of Wisconsin Experience Laryngoscope 2004;114:969­974 Meco C, Oberascher G. Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid Fistula Diagnosis. Laryngoscope 2004;114:991­999 Mirza S, et al. Sinonasal Cerebrospinal Fluid Leaks: Management of 97 Patients Over 10 Years. Laryngoscope 2005;115:1774­1777 Keerl R, et al. Use of Sodium Fluoroscein Solution for Detection of Cerebrospinal Fluid Fistulas. Laryngoscope 2004;114:266­272 Carrau RL, et al. The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High­Pressure Hydrocephalus. Laryngoscope 2005;115:205­212 Han CY, Backous DD. Basic Principles of Cerebrospinal Fluid Metabolism and Intracranial Pressure Homeostasis. Otolaryngol Clin N Am 2005;38:569­576 Meco C, et al. B­Trace protein test: New guidelines for the reliable diagnosis of cerebrospinal fluid fistula. Otolaryngol Head Neck Surg 2003;129:508­517 Schnabel C, et al. Comparison of B2­transferrin and B­trace protein for detection of Cerebrospinal Fluid in Nasal and Ear Fluids. Clinical Chemistry 2004;50:661­663 Zweig JL, et al. Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: Predictors of success. Otolaryngology­Head and Neck Surgey 2000;123:195­201 Schlosser RJ, Bolger WE. Endoscopic Management of Cerbrospinal Fluid Rhinorrhea. Otolaryngol Clin N Am 2006;39:523­538 Chatrath P, Saleh HA. Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea using Bone Pate. Laryngocope 2006;116:1050­1053 ...
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