1. Gupta Madan ,Singh Shuchita,Verma Rohit, Thakar Alok
Department of Otorhinolaryngology and Head – Neck Surgery
All India Institute of Medical Sciences, New Delhi
Spontaneous leak
Introduction
Site of leak
Cerebrospinal fluid (CSF) rhinorrhoea results due to an aberrant communication
between subarachnoid space and nasal cavity1
Could be spontaneous, traumatic, iatrogenic or congenital
Failed medical management mandates surgery
Trans-nasal endoscopic approach (TER)to skull base revolutionized CSF
rhinorrhoea treatment making repair less invasive with more than 90% success
rates after first repair2
Key point in TER is accurate identification of leak site3
Aims & Objective
4 patients had recurrence (7.8%), out of which 2 required revision surgery while the
rest were managed conservatively
To analyze and evaluate the long-term surgical outcomes and recurrence rates of
trans-nasal endoscopic repair (TER) of CSF leak
The success rate of our study was -
To determine the prognostic factors governing treatment success
Success rate at Ist attempt – 92.2% (47/51)
To identify the high risk factors for recurrent CSF leaks
Success rate at IInd attempt – 98% (50/51)
To correlate CSF leak recurrence with various clinical parameters (etiology, sex,
BMI, leak site)
Materials and Methods
Recurrences
Pt
Retrospective study of 52 consecutive patients of CSF rhinorrhoea (52 primary
and 4 recurrent), treated at a single tertiary care centre over a period of 14 years
(1999 - 2013)
1
Epidemiological parameters and clinical presentation of all patients were noted
2
The patients were subjected to TER for CSF leak
The surgical outcomes were analyzed by serial clinical evaluation and nasal
endoscopy for a follow up period ranging from 2 to 14 years (median 7 years)
All the epidemiological and clinical parameters defining the success or failure of
treatment outcome were evaluated
3
4
Recurrence of CSF leak was correlated with various clinical parameters (etiology,
sex, BMI, leak site)
Results
Primary/Recurrent ratio – 52 : 4
Male/Female ratio – 1 : 1.08
Age Range was 3 to 63 years (median 31 years)
Invariably all patients presented with clear watery nasal discharge, followed by
headache and anosmia in 57% and 22% patients respectively
21 patients (40.38%) had previous history of meningitis
Age Distribution
Clinical Presentation (Frequency)
Age
Site Size Etiology Comorbiditie Time of BMI
(yrs)/Sex
(mm)
s
recurr.
46/F
43/F
9/F
57/F
CP
SPH
CP
SPH
20
35
30
50
Spon.
Spon.
Traum.
Spon.
DNS
HT+DNS
HT+DM
Placemen
t
Spinal
drain
(days)
29
Abd.
Fascia+ fat
Overlay
Yes (3)
10-20
33
Abd.
Fascia+ fat
Overlay
Yes (3)
90-120
Fascia lata +
11
fat
Overlay
No
30-40
Fascia lata +
35
fat
Overlay
Yes (4)
180-220
Graft
Discussion
Dandy (1926) – First intracranial CSF leak repair –high morbidity and complication
risks with 60% success rate4
Dohlman (1948) – First extracranial CSF leak repair – less complications with a
success rate of 60 – 80%5
Wigand (1981) – First endo-nasal endoscopic CSF repair- low morbidity and high
success rates of 90% after the Ist attempt and 95-98% after IInd repair6
Advantages of TER - excellent field of vision, exact localization of leak, better
evaluation and quantification of bony defect, better chances of placing the most
suitable graft for leak repair, reduced invasiveness and hospitalization time.
Presence of I/C haematoma, fractures of ethmoid, orbital roof or posterior wall of
frontal sinus limits endoscopic repair
In accordance with previous studies7, our study also shows success rate of 92.2%
after Ist repair (4 recurrences), which increases to 98% after IInd surgery (1
recurrence)
As reported by various authors8, cribriform plate was the commonest site of leak in
this study as well
In present study recurrences were seen in female patients with a higher value of BMI
BMI ranged from 11 to 38, with a mean of 25
A higher BMI was noted in female population (mean 26.5) as compared to males
(mean 23.5)
Conclusion
Majority of patients belonged to post traumatic and spontaneous group with 42%
patients in each
In recent advancement technology, the preferred modality of CSF
rhinorrhea should be endoscopic endonasal with high success rate and
lower morbidity.
Spontaneous CSF rhinorrhoea was commoner in females (90%)
Majority of patients with spontaneous leak had higher BMI (mean 30)
Right sided CSF leak was commoner than left (70% vs 30%)
Lateral lamella of cribriform plate (58.8%) was the commonest leak site, followed
by fovea ethmoidalis (23.5%) and sphenoid leak (11.7%)
Traumatic leaks predominantly had fossa ethmoidalis defect, however, defect in
cribriform plate was equally distributed in spontaneous and traumatic groups
No significant complication
BMI distribution
Etiology
References
1.
Ahmed Soliman Ismail et al : Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage
Using Multilayer Acellular Dermis : Skull Base / Volume 17, Number 2 2007; 125-132.
2.
Michele Cassano et al: Endoscopic treatment of cerebrospinal fluid leaks with the use of lower
turbinate grafts: a retrospective review of 125 cases : Rhinology, 47, 362-368, 2009
3.
L. Presutti et al : Transnasal endoscopic treatment of cerebrospinal fluid leak: 17 years’
experience : Actarhinolaryngologica ITALICA: 2009;29:191-196
4.
Castelnuovo P et al: Endoscopic repair of cerebrospinal fluid rhinorrhea: learning from our
failures.Am J Rhinol 2001;15:333-42.
5.
Dohlman G: Spontaneous cerebrospinal rhinorrhea. Acta Otolaryngol Suppl 1948;67:20-3.
6.
Wigand ME: Transnasal ethmoidectomy under endoscopical control. Rhinology 1981;19:7-15.
7.
Achkar Jet al: Endoscopic endonasal repair of csf rhionorrhea.2009;10.
8.
Schlosser R et al : Endoscopic management of csf rhionorrhea. Otolaryngol clin north
Am.2006;39:523-38.
Skull base conference 2013, PGI, Chandigarh