Endoscopic repair of frontal sinus cerebrospinal fluid leaks

Pediatric Congenital Anterior Skull Base Encephaloceles and Surgical Management: A Comparative Review of 22 Patients Treated With Transnasally, Transcranially, or Combined Approach With a Review of the Literature

BACKGROUND AND OBJECTIVES

Anterior basal encephaloceles are considered a rare entity and are often associated with midline cerebral abnormalities. Those with a large skull base defect and herniation of brain parenchyma in the neonate or young infant present unique challenges for surgical management.

METHODS

We analyzed the neurosurgical administrative and operative databases between 1986 and 2022 to determine clinical presentation, operative approach, and outcome of basal encephaloceles.

RESULTS

Over the 36-year period, 27 pediatric anterior basal encephaloceles were managed, of which 22 had full documentation and images allowing comprehensive review. Mean age at presentation was 5 years (SD 4.94). The majority were transethmoidal encephaloceles (59%), followed by the transsphenoidal-sphenoethmoidal type (32%). Overall, 91% were managed surgically by a transcranial, endoscopic, or combined approach. Four children required subsequent procedures, predominantly for persistent cerebrospinal fluid leak. No significant differences in proportion of patients requiring interval/revision surgery after initial conservative, endoscopic endonasal, or transcranial surgery was identified. Neither age at surgery nor size of the defect on computed tomography scan was associated with the need for revision surgery. Size of cranial defect was significantly smaller in the endoscopic group (P = .01). There was a historic tendency for younger children with larger defects to have a transcranial approach. With the addition of endoscopic skull base expertise, smaller defects in older children were more recently treated endoscopically.

CONCLUSION

Basal encephaloceles are rare and complex lesions and are optimally managed within a skull base multidisciplinary team able to provide multiple approaches. Large skull base defects with brain parenchymal involvement often require a transcranial or combined transcranial-endoscopic approach.

Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review

Cerebrospinal fluid leak (CSFL) is a rare pathological condition which requires prompt and adequate management due to the high rate of associated major complications. At present, CSFL can be successfully treated through endoscopic endonasal approaches with success rates higher than 90%. Despite this, CSFL recurrence may occur, and its management is critical and still represents a matter of debate. A systematic review of the literature on the management of recurrent CSFL was conducted. It included a cohort of 1,083 cases of CSFL treated with surgical or conservative approaches; 112 cases of recurrence were reported for an overall recurrence rate of 10.3%. Most of the leaks were localised in the anterior skull base (68.3%) and identification of recurrent CSFL may be troublesome. Therefore, the entire skull base must be meticulously examined and long-term follow-up is mandatory. The risk for CSFL recurrence is higher in patients affected by idiopathic intracranial hypertension (IIH), but its role in CSFL recurrence is yet to be understood. Recurrent CSFL must be repaired as soon as possible in order to reduce the risk of intracranial complications. The use of early post-operative CSF diversion by lumbar drain (LD) is currently a matter of debate even in case of CSFL recurrences.

Defining the limits and indications of the Draf III endoscopic approach to the lateral frontal sinus and maximizing visualization and maneuverability: a cadaveric and radiological study

PURPOSE

The DRAF III procedure has been used for access to the lateralmost part of the frontal sinus. We sought to identify anatomical and radiological measurements as well as modifications that predict the lateral limits of visualization and surgical access after this procedure.

METHODS

Seven cadaver heads were imaged with computed tomography scan. The distance from midline to the medial orbital wall (MOWD), midline to the lateral end of the frontal sinus (MLD), the sum of MLDs (SMLD), interorbital distance (IOD) and the shortest anteroposterior distance of the frontal recess (APD) were utilized. The ratios MLD/MOWD, and SMLD/IOD were calculated. The same distances were measured on 41 CT scans. Orbital transposition (OT) and partial resection of the piriform aperture (PAR) were performed; the visualization and reach were assessed. The angle of insertion was measured before and after the modifications.

RESULTS

Only the ratio MLD/MOWD was consistently predictive of access to the lateral, superior and posterior wall of the frontal sinus. Following the modifications, a visualization of 100% laterally was achieved with the 30- and 45 degree endoscopes and every lateral recess could be reached with the 70 degree suction. A mean increase of the angle of insertion of 25.3 and 59.6% was recorded after OT and PAR, respectively.

CONCLUSIONS

IOD rather than APD defines the limits of the Draf III approach to the lateral frontal sinus and MLD/MOWD ratio can serve as a useful preoperative tool. Along to the already described OT, PAR increases visualization and reach of the lateral frontal sinus.

Outcome of the endoscopic repair of frontal sinus cerebrospinal fluid leak

Introduction

and Objectives: Leakage of cerebrospinal fluid (CSF) from the frontal sinus is a challenging condition facing the ENT surgeon. Repair of this condition has been changed nowadays due to the newer instruments and techniques of nasal endoscopy. This study aims to evaluate the outcome of frontal sinus CSF leak endoscopic repair.

Patients and methods

Twenty-seven patients who had frontal sinus CSF leaks were included in this study. They were 9 females and 18 males. They underwent endoscopic repair of the leak site at the period of five years from 2015 to 2020. A retrospective evaluation of these patients includes reconstructive procedures, complications, and postoperative follow-up.

Results

The frontal leaks were present in the frontal recess (8 patients, 29.6%), ethmoidal roof (5 patients, 18.5%), and the majority was in the posterior wall (14 patients, 51.9%); 11 in the medial side and 3 in the lateral side. All cases, 27 (100%) were treated successfully, no failed treatment was observed. Postoperative complications were minimal; two patients had elevated intracranial pressure (ICP), infection with fever were found in four patients (7.4%), and meningitis was observed in only two cases (7.4%), treated conservatively.

Conclusion

For frontal sinus CSF leak repair, the endonasal endoscopic approach is the treatment of choice due to higher success rates and lower morbidity profile. A favorable result is possible with proper diagnosis, precise localization, and an appropriate strategy.

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CSF leakage from the frontal sinus is a challenging condition for ENT surgeons.

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Repair has been changed nowadays due to the newer techniques of nasal endoscopy.

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We report favorable results of the endonasal endoscopic approach in 27 patients.

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Proper diagnosis and precise localization are acheived.

Above and Beyond: Periorbital Suspension for Endoscopic Access to Difficult Frontal Sinus Pathology

OBJECTIVES/HYPOTHESIS

The periorbital suspension (PS) is an advanced adjunctive technique performed during endoscopic approaches to frontal sinus pathology that would be too far lateral or superior to address using traditional endoscopic transnasal approaches. The objectives of this study are to characterize the utility of this technique for frontal sinus pathology, determine anatomic limitations, and assess clinical outcomes following surgical treatment.

STUDY DESIGN

Prospective case series.

METHODS

Patient data including demographics, etiology, technique, complications, and clinical follow-up were collected. Preoperative computed tomography scans were reviewed for maximum lateral and superior extent of pathology, supraorbital recess height, anterio-posterior (AP) diameter of the frontal sinus, interorbital distance, and orbital-first olfactory neuron distance.

RESULTS

The PS approach was used in 30 surgeries (29 patients) for cerebrospinal fluid leaks (n = 5), benign tumors (n = 17), malignant tumors (n = 5), allergic fungal sinusitis (n = 2), and mucocele (n = 1) between 2018 and 2020. Approaches included 15 Draf IIB and 15 Draf III frontal sinusotomies. All pathology was surgically accessible using the PS approach and there were no intraoperative or postoperative complications. Postoperative follow-up was 11.7 ± 7.6 months. Mean recorded measurements (in mm) were as follows: maximum lateral extent -15.0 ± 7.7, superior extent 21.2 ± 7.7 in surgical plane and 20.9 ± 9.8 in the vertical plane, supraorbital recess height -2.6 ± 1.9, AP frontal sinus diameter -13.2 ± 4.7, interorbital distance -29.8 ± 5.4, and orbital-olfactory neuron distance -14.8 ± 2.9.

CONCLUSIONS

The PS technique can be safely and successfully utilized to provide endoscopic endonasal access to lateral and superior frontal sinus pathology.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Frontal Sinus Fractures: A Review on Etiology and Management Emphasizing Minimally Invasive and Endoscopic Techniques

ABSTRACT

In spite of a long and tortuous history of the acute management of frontal sinus fractures, current optimal management remains steeped in controversy. These fractures are frequently produced by excessive forces and are often accompanied with other injuries. However, disruption of the nasofrontal duct persists as essential to maintain proper sinus function and should guide current management. Although there has never been any distinct procedure defining optimal outcomes, proper treatment is contingent on precise diagnosis culled from a complete history, physical examination, and imaging studies. This is further augmented by the surgeon's intraoperative findings. Reconstruction will ultimately rest on the degree of disruption of the anterior and posterior sinus walls, as well as the status and function of the nasofrontal ducts. For these reasons, current management continues to be challenging and evolving. Thus, this review will discuss the etiology and clinical presentation of frontal sinus fractures, the current complications arising in the subject, and the evolution of treatment options towards a more conservative and endoscopic approach to care.

Compartmentalization: An Open Technique for Frontal Sinus Repair and Preservation-Description of Technique and Early Case Series

Background  Cranialization or obliteration is widely accepted intervention for traumatic or intentional breach of the frontal sinus. These techniques, however, result in the loss of frontal sinus function and have a persistent risk of cerebrospinal fluid (CSF) leak and mucocele. Compartmentalization is an open technique for repair of the frontal sinus using allograft onlay and a vascularized periosteal flap that allows for preservation of frontal sinus function. Objective  The main objective of this article is to describe the technique for compartmentalization of the frontal sinus and demonstrate its efficacy and complication rate with an early patient series. Methods  Our technique includes the following key components: harvesting of a pedicled periosteal flap, frontal sinus repair through a bifrontal craniotomy with minimal mucosa removal, ensuring the patency of the nasal frontal outflow tract, and separation of the brain from the frontal sinus with a dual layer of periosteum and allograft. All cases of frontal sinus repair using the compartmentalization technique at our institution were reviewed. Charts were reviewed for CSF leak, mucocele, and other complications. Results  Twenty-three patients underwent the described frontal sinus repair technique 17 for tumor and 6 for trauma. There were no CSF leaks and no mucoceles. One patient experienced postoperative anemia and a "parameningeal reaction" that were managed with a short course of antibiotics. Conclusions  Compartmentalization, due to its sinus preservation and low complication rate, represents a meaningful step forward in neurosurgical technique for open frontal sinus repair. However, long-term outcomes are necessary to fully evaluate risk of mucocele.

Transorbital Endoscopic Approach for Repair of Frontal Sinus Cerebrospinal Fluid Leaks: Case-Series

OBJECTIVES

To highlight the feasibility and evaluate the outcomes of the transorbital endoscopic approach (TOEA) in the management of frontal sinus cerebrospinal fluid (CSF) leaks.

STUDY DESIGN

Retrospective case series.

METHODS

The database of patients with frontal sinus CSF leaks managed with TOEA from January 2017 through December 2019 at our institution was reviewed. Two videos of clinical case examples are presented.

RESULTS

Sixteen patients (10 males, 6 females, mean age 53; range 21-61 years) underwent TOEA through the superior eyelid corridor for the repair of frontal sinus CSF leak. The most common etiology of the CSF leak was trauma (nine cases; 56.3%), followed by injury from iatrogenic causes in six cases (37.5%), and spontaneous leak in one case (6.2%). Average defect size was 8.8 mm (range 2.0-20.8 mm). Ten patients were revision cases who had undergone prior nontransorbital CSF leak repair at outside institutions. All patients underwent successful repair via TOEA without postoperative complications. Complete resolution was maintained in all cases. Mean follow-up period was 11 months (range 6-22 months).

CONCLUSIONS

TOEA is a safe minimally disruptive alternative for definitive management of frontal sinus CSF leak in well-selected primary or revision cases. Further studies are necessary to define its indications and outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1753-1757, 2021.

Endoscopic management of frontal sinus CSF leaks

Introduction

Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition.

Objective

To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach.

Methods

A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined.

Results

Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 − 41 months).

Conclusion

Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Frontal sinus fractures and cerebrospinal fluid leaks: a change in surgical paradigm

PURPOSE OF REVIEW

Traditionally, frontal sinus trauma has been treated using open incisions to access the anterior and/or posterior table. Mounting evidence indicates frontal sinus trauma can be managed using an endoscopic endonasal approach (EEA) with less morbidity. Such an approach permits preservation of a functional sinus and less reliance on computed tomography for postoperative follow up. The goal of this article is to highlight a shift in paradigm away from open approaches using external incisions towards an EEA to repair cerebrospinal fluid (CSF) leaks and fractures of the frontal sinus.

RECENT FINDINGS

In a prospective case series of 46 patients undergoing EEA to frontal sinus fractures, 41 patients had active CSF leaks arising from the posterior table of the frontal sinus. A successful endoscopic repair was achieved in 97.6% with only one patient requiring revision Draf IIB surgery. Anterior table fractures were also successfully reduced with excellent cosmesis.

SUMMARY

Endoscopic repair of frontal sinus fractures and CSF leaks is effective and well tolerated. In select patients, it is the preferred treatment as it maintains normal sinus structure and function, minimizing both early and late complications.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

[Modern aspects of surgical treatment of nasal liquorrhea with localization of defect in frontal sinus]

Defects localized in the frontal sinus are difficult for surgical treatment, since there is a large number of anatomical variations in the structure of the naso-frontal canal and the sinus itself. With the development of endoscopic technology and paying attention to the modern tendency of minimal invasive surgery, new invasive approaches to reach frontal sinus, such as endoscopic approach according to Draf I-III and combined approaches were developed and put into practice.

OBJECTIVE

To summarize and to analyze the results of treatment of nasal liquorrhea with localization of the defect in the frontal sinus using endoscopic endonasal and combined intra-extranasal approaches.

MATERIAL AND METHODS

A retrospective analysis of a series of 43 cases of nasal liquorrhea with a frontal sinus defect being treated at the NMRCN Burdenko during the period from 2001 to 2017. To select access, a classification of frontal sinus defects according to their localization was developed. The analysis of demographic and clinical data of patients, as well as intraoperative and postoperative data analysis were done.

RESULTS

In the series of 43 patients, endoscopic endonasal approach was performed in 28 (65%) cases. Combined approach was performed at 15 (35%) patients. The success rate of plastic surgery with endoscopic endonasal approach was 86% (24 of 28), with combined approach - 93% (14 of 15).

CONCLUSION

Endoscopic endonasal and combined approaches are the methods of choice for plastic surgery of defects of the skull base in the frontal sinus as they are effective and safe. The choice of approach depends on anatomical features of the frontal sinus and on the localization of defect.

Frontal Sinus Fractures: Evolving Clinical Considerations and Surgical Approaches

Frontal sinus fractures are an uncommon injury of the maxillofacial skeleton, and account for 5-15% of all maxillofacial fractures. As the force of impact increases, fractures may extend beyond the anterior table to involve adjacent skull, posterior table and frontal sinus outflow tract (FSOT). Fractures at these subsites should be evaluated independently to assess the need for and type of operative intervention. Historically, these fractures were managed aggressively with open techniques resulting in obliteration or cranialization. With significant injuries, these approaches are still indispensable. However, the treatment of frontal sinus fractures has changed dramatically over the past half-century, and recent case series have demonstrated favorable outcomes with conservative management. Concurrently, there has been an increasing role of minimally invasive endoscopic techniques, both for primary and expectant management, with a focus on sinus preservation. Here, we review the diagnosis and management of frontal sinus fractures, with an emphasis on subsite evaluation. Following a detailed assessment, an appropriate treatment strategy is selected from a variety of open and minimally invasive approaches available in the surgeon's armamentarium.

Degree of Frontal Bone Exposure via Upper Blepharoplasty Incision: Considerations for Frontal Sinus Fracture

OBJECTIVE

The upper eyelid blepharoplasty incision affords direct access to the frontal bone for skull base surgery and trauma reconstruction with a well-hidden scar. The goal of this study is to quantify frontal bone exposure that can be achieved with an upper eyelid blepharoplasty incision.

DESIGN

Anatomic study with human cadaver heads.

SETTING

UC Davis Medical Center.

SUBJECTS/METHODS

Fourteen human cadaver heads were used to perform 26 upper blepharoplasty approaches. Exposure was measured with virtual planning software to create virtual reference points at the midline of the superior orbital rim. Surgical navigation was used with a 3-dimensionally printed drill model to measure the maximum exposure achievable relative to the virtual reference point at 5 standardized angles.

RESULTS

Mean ± SD exposures at medial 60°, medial 30°, 0°, lateral 30°, and lateral 60° were 16.1 ± 1.3 mm, 17.8 ± 1.3, 18.3 ± 1.4, 19.3 ± 1.9, and 20.9 ± 1.9, respectively. Significant differences were detected between exposures at 60° laterally and 60° medially and between exposures 60° laterally and 30° medially ( P < .05).

CONCLUSIONS

The upper eyelid blepharoplasty incision provides direct surgical access to the inferior frontal bone. Access was greatest with far lateral extension (mean, 20.9 mm) and most limited with far medial extension (mean, 16.1 mm). Treatment of injuries above this level could be achieved with additional percutaneous incisions for screw placement.

Endonasal endoscopic management of frontal sinus cerebrospinal fluid leak

BACKGROUND

A frontal sinus leak is uncommon and is seen in ∼15% of cases of patients with cerebrospinal fluid (CSF) rhinorrhea. Now, endonasal endoscopic techniques have been reported to reconstruct skull base defects in the frontal sinus with a favorable outcome.

OBJECTIVE

To review our experience in the repair of frontal sinus CSF leaks through an endonasal endoscopic approach.

METHODS

Twenty-four patients with a frontal sinus leak who underwent endonasal endoscopic repair entered the study. Clinical presentation, location, frontal sinusotomy, graft material, follow-up, and frontal sinus status were evaluated.

RESULTS

Among >100 cases of surgically repaired CSF rhinorrhea, the frontal sinus was the site of the leak in 24 patients (mean age, 28.9 years; mean follow-up, 22 months). The etiology consisted of spontaneous leak and traumatic leak; whereas patients with skull base reconstruction after removal of tumor were excluded. Surgical approaches included Draf IIb, Draf III, Draf IIa in 20, 3, and 1 patients, respectively. Free autografts as two-layer inlay fat-muscle and onlay fascia lata were used in the majority of patients. A success rate was achieved in 95.83% of the patients.

CONCLUSION

Endonasal endoscopic repair of a frontal sinus leak was a successful procedure, with a low failure rate and minimal morbidity.

Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling

BACKGROUND

To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing.

METHODS

In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases.

RESULTS

Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion.

CONCLUSION

This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.

Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

Background  The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable. Methods  Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed. Results  Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture ( n  = 32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions  Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.

Transnasal endoscopic and combined intra-extranasal approach for the surgical treatment of frontal sinus cerebrospinal fluid rhinorrhea

The aim of this study was to summarize and analyze the outcomes of frontal sinus cerebrospinal fluid rhinorrhea (FS-CSFR) treated by transnasal endoscopic and combined intra–extranasal approach. Clinical data on 20 cases of FS-CSFR patients from 2005 to 2013, with emphasis on the postoperative complications, clinical outcomes, and key technology involved in the combined intra–extranasal procedure, were retrospectively reviewed. Among the 20 cases, 12 were treated by combined intra–extranasal procedure; the other eight cases were initially treated by trans-nasal endoscopic approach alone, and five of them (5/8, 62.5%) were successfully treated and three failed. The three failed cases subsequently underwent combined intra–extranasal approach. A total of 15 cases, who received combined procedure, experienced fast recovery, had mild complications, and had no significant facial scars, and no CSFR recurrence was observed. Combined intra–extranasal approach offers advantages in not only overcoming the difficulty of insufficient exposure of defects during transnasal endoscopic procedure but also improving the success rate of repair.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair

BACKGROUND

Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case-series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques.

METHODS

Prospective evaluation of patients undergoing surgery for frontal sinus fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of skull base defects, complications, and clinical follow-up.

RESULTS

Forty-six patients (average age, 42 years) with frontal sinus fractures were treated using endoscopic techniques from 2008 to 2016. Mean follow-up was 26 (range, 0.5 to 79) months. Patients were treated primarily with a Draf IIb frontal sinusotomies. Draf III was used in 8 patients. Average fracture defect (length vs width) was 17.1 × 9.1 mm, and the average length involving the posterior table was 13.1 mm. Skull base defects were covered with either nasoseptal flaps or free tissue grafts. One individual required Draf IIb revision, but all sinuses were patent on final examination and all closed reductions of anterior table defects resulted in cosmetically acceptable outcomes.

CONCLUSION

Frontal sinus trauma has traditionally been treated using open approaches. Our findings show that endoscopic management should become part of the management algorithm for frontal sinus trauma, which challenges current surgical dogma regarding mandatory open approaches.

Contemporary Trends in the Management of Posttraumatic Cerebrospinal Fluid Leaks

The objective of this review is to provide an overview on the diagnosis and management of traumatic cerebrospinal fluid (CSF) leaks. This comprehensive review explores controversies associated with the management of CSF leaks as well as a review of the most contemporary literature. The scope of this article covers both traumatic CSF leaks of the middle and anterior cranial fossae.

Endoscopic management of cerebrospinal fluid rhinorrhea

Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.

Purely endoscopic pterional extradural approach: A novel technique for repair of cerebrospinal fluid rhinorrhea

STUDY DESIGN

Retrospective descriptive study of an innovative surgical technique.

OBJECTIVE

To assess the feasibility and success of repair of transfrontal sinus cerebrospinal fluid (CSF) rhinorrhea through pterional transcranial extradural approach using endoscope.

SUMMARY OF BACKGROUND DATA

Repair of CSF rhinorrhea has seen advancement with the evolution of endoscopic transnasal techniques. However, leaks from defect in the posterior wall of frontal sinus still remain a challenge for the skull base surgeons and requires conventional craniotomy more often. We describe a novel technique to repair these leaks by purely endoscopic pterional extradural (PEPE) approach thereby avoiding complications associated with conventional craniotomy and endoscopic transnasal approaches.

MATERIALS AND METHODS

Thirty-five patients with traumatic CSF rhinorrhea from the posterior wall of frontal sinus underwent repair with the present technique. They were followed up for 6-18 months and were evaluated for feasibility of procedure, recurrence of leak, and occurrence of the fresh neurological deficit.

RESULTS

Thirty-five patients underwent CSF rhinorrhea repair using the above technique. The procedure was accomplished in all patients without any intraoperative complications. There was no requirement of blood transfusion in any case. All patients had a cessation of CSF leak in the postoperative period, and there was no recurrence. There was no evidence of frontal lobe retraction injury in any of these patients, and no fresh neurological deficit was observed.

CONCLUSION

This PEPE approach to repair CSF leak through the posterior wall of the frontal sinus is a novel technique in which we can avoid disadvantages associated with both conventional craniotomy as well as transnasal endoscopic approaches.

Endoscopic Endonasal Repair of Spontaneous and Traumatic Cerebrospinal Fluid Rhinorrhea: A Review and Local Experience

This article presents an overview of endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea. In recent years, endoscopic repair has become the standard of care for managing this condition, because it gradually replaces the traditional open transcranial approach. Discussion includes the etiologic classification of CSF rhinorrhea, management paradigm for each category, diagnosis algorithm, comprehensive description of the surgical technique, and an updated review of the literature regarding the safety and efficacy of this procedure. In addition, the authors present their experience, including 2 surgical videos demonstrating endoscopic repair of CSF rhinorrhea in 2 distinct clinical scenarios.

State of the art of endoscopic frontal sinus cerebrospinal fluid leak repair

Frontal sinus cerebrospinal fluid leaks are rare and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach can now be used, ensuring a simpler postoperative course. However, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency.

Endoscopic Repair of Frontal Sinus Cerebrospinal Fluid Leaks after Firearm Injuries: Report of Two Cases

Objectives To describe two cases of cerebrospinal fluid (CSF) leak repair after gunshot wound to the head.

Design Retrospective review of two cases.

Settings A large regional tertiary care facility.

Participants Two patients with gunshot wounds to the skull base.

Main Outcome Measures Preoperative and postoperative physical and radiologic findings.

Results Patients in this series underwent endoscopic surgery, debridement, and repair of CSF leaks after gunshot wounds to the head. To date, the patients are without CSF leak.

Conclusions Endoscopic closure of anterior skull base CSF leaks in patients with gunshot wounds can be safe and effective. Treatment should be decided by the severity of neurologic deterioration throughout the emergency period and the existence or absence of associated intracranial lesions. Timing for surgery should be decided with great care and with a multidisciplinary approach.

Geographic and temporal trends in frontal sinus surgery

BACKGROUND

The purpose of this study was to evaluate geographic and temporal trends in frontal sinus surgery procedures.

METHODS

Medicare Part B data files from 2000 to 2011 were examined for temporal trends in various frontal sinus procedures, and the most recent year containing geographic information (2010) was evaluated for Current Procedural Terminology (CPT) code use. Additionally, nationwide charges per procedure were recorded. Regional populations of individuals ≥ 65 years old were obtained from the 2010 U.S. Census, and surgical society websites were used to determine the number of practicing rhinologists and otolaryngologists in each region.

RESULTS

The use of open approaches declined by one third, while endoscopic procedures went from 6463 to 19262 annually, with the most marked increases occurring from 2006 through 2011. Geographic variation was noted, with practitioners in the South Atlantic states performing the greatest number of endoscopic procedures in 2010, whereas the East South Central states had the greatest number when controlling for population. There was an inverse relationship between endoscopic procedures performed and number of fellowship-trained rhinologists (controlling for regional populations) (R(2) = 0.66). The first year frontal sinus ballooning had a unique CPT code illustrated decreased reimbursements for non-balloon endoscopic surgery ($609) relative to balloon approaches ($2635).

CONCLUSION

Declines in open frontal sinus surgery and marked increases in endoscopic approaches have potential implications for residency training. Potential reasons for marked increases in endoscopic approaches include the rising popularity of balloon technologies, although this is speculative. Geographic variation exists in frontal sinus surgery patterns, including an inverse relationship between endoscopic approaches and the number of fellowship-trained rhinologists.

Increased Intracranial Pressure in Spontaneous CSF Leak Patients Is Not Associated with Papilledema

Objective

Spontaneous cerebrospinal fluid (CSF) leaks typically present in patients with undiagnosed idiopathic intracranial hypertension (IIH) secondary to pressure erosion of the skull base. Despite elevated intracranial pressure (ICP) on lumbar puncture or ventriculostomy, patients with spontaneous CSF leaks rarely complain of visual disturbances. The objective of this study is to correlate the presence of preoperative papilledema with opening ICP in patients undergoing endoscopic repair of spontaneous CSF leaks.

Study Design

Prospective study.

Setting

Tertiary hospital.

Methods

Prospective evaluation of patients with spontaneous CSF leaks was performed over a 1-year period (December 2012 to December 2013). Fundoscopic examination for papilledema was completed preoperatively and CSF pressure measured by lumbar puncture or ventriculostomy intraoperatively. Data regarding demographics, nature of presentation, and body mass index (BMI) were also recorded and compared to a control cohort of IIH patients with papilledema.

Results

Sixteen patients (average age 52) were evaluated. Obesity was present in 94% of individuals (average BMI = 43, range, 27-65). Papilledema was absent preoperatively in all subjects. Opening pressures via lumbar puncture/ventriculostomy were 27.4 ± 7.7 cmH20. Following 6 hours of clamping, measurements significantly increased to 36 ± 9.6 cmH20 ( P < .001). IIH controls (average age 33, average BMI = 36, range, 21-52) exhibited average ICP (36.2 ± 11.7) identical to postclamp measurements in the spontaneous CSF leak cohort.

Conclusions

Subjects with spontaneous CSF leaks had postclamping average ICP identical to controls with IIH and papilledema. Such evidence suggests that a CSF leak in this patient population provides sufficient pressure diversion to avoid the development of papilledema.

Management of Lateral Frontal Sinus Pathology in the Endoscopic Era

OBJECTIVES

Considerable advances in endoscopic technique and experience have allowed an increasing number of patients with complex frontal sinus disease to be treated with endoscopic surgery. The objective of the current study was to evaluate management strategies and outcomes regarding treatment of lateral frontal sinus disease.

STUDY DESIGN

Prospective case series.

SETTING

Academic tertiary medical center.

SUBJECTS AND METHODS

Prospectively collected data concerning frontal sinus pathology located lateral to the plane of the lamina papyracea (lateral disease) were reviewed. Data were collected regarding demographics, etiology, surgical technique, revision rate, anatomic considerations, and clinical follow-up. Only patients with at least 24 weeks of clinical follow-up and pathology who required removal and dissection in this region were included in the study.

RESULTS

Over 5 years, 156 patients (mean age, 47.9 years; range, 14-84 years) with 183 lateral frontal sinus pathologies and an average clinical follow up of 76 weeks (range, 24-237 weeks) were evaluated. Endoscopic or open surgery was attempted in 84 patients (54%) prior to intervention at our institution. Primary pathologies included inflammatory/obstructive diseases (n = 119), skull base defects (n = 33), and tumors (n = 31). Initial interventions included endoscopic (Draf IIA, n = 76; Draf IIB, n = 52; Draf III, n = 23), extended (IIA + trephine, n = 1; III + trephine, n = 2; III + osteoplastic flap, n = 2), and open (osteoplastic flap, n = 3; Reidel, n = 1; cranialization, n = 1) procedures. Seven patients (4%) required a subsequent revision procedure.

CONCLUSION

The vast majority of lateral frontal sinus pathology was managed using endoscopic techniques with excellent outcomes and a low revision rate in the current study.

Managing the frontal sinus in the endoscopic age: has the endoscope changed the algorithm?

Management of fractures involving the frontal sinus seems to be more complex than merely obtaining an ideal reduction of the bony injuries. Multiple articles on the management of these fractures suggest that a great deal of controversy persists despite many years of surgical experience. The question posed in this article is whether or not the advent of endoscopic approaches has changed or should change the approaches/algorithms used in the management of these challenging fractures. It is the conclusion of these authors that endoscopic techniques can indeed allow us to change the algorithm for management of frontal sinus trauma. New algorithms are proposed that should provide guidance to craniomaxillofacial surgeons treating these injuries in the endoscopic age.

Transnasal endoscopic repair of posterior table fractures

OBJECTIVES/HYPOTHESIS

Conventional treatment of frontal sinus posterior table fractures has included osteoplastic flap or cranialization procedures despite considerable advances in endoscopic technique and experience. The objective of the current study was to evaluate outcomes of frontal sinus fractures involving the posterior table managed using endoscopic approaches.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary care, academic university hospital.

METHODS

Prospective evaluation of patients with posterior table fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of the skull base defect, complications, and clinical follow-up.

RESULTS

Thirteen patients (average age 37 years) with posterior table fractures were treated using endoscopic techniques from 2008 to 2012. Mean follow-up time was 68 weeks (range, 2-206 weeks). Patients were primarily managed using Draf IIb frontal sinusotomies with 1 individual requiring a concomitant trephine. A Draf III procedure was performed in 1 patient. Average fracture defect (length vs width) was 13 × 4.5 mm, and average length involving the posterior table was 9.7 mm (1-30 mm). Skull base defects were covered with a septal flap and/or free tissue grafts. Although 1 individual required a revision frontal sinusotomy and follow-up was short in several patients, all sinuses remained patent on last clinical examination.

CONCLUSION

Management of frontal sinus posterior table fractures using minimally invasive endoscopic techniques provides excellent outcomes in selected cases. Fractures of up to 30 mm in length were adequately managed in this series and indicate this approach can be a viable alternative in the treatment of these fractures.

Unilateral endoscopic approach for repair of frontal sinus cerebrospinal fluid leak

Cerebrospinal fluid (CSF) leak closure remains one of the most difficult surgeries for skull base surgeons, particularly with frontal sinus involvement. Technological advances in endoscopic surgery increasingly allow for less morbid approaches to the frontal sinus. We describe a series of patients who underwent endoscopic frontal sinus CSF leak repair utilizing a unilateral approach, to evaluate the utility and outcomes of this method. We performed a retrospective review of four cases in tertiary care centers. Participants included patients with CSF leak involving the frontal sinus. Main outcome measures included cessation of CSF leak and frontal sinus patency. Three patients were closed on the first surgical attempt; one with a communicating hydrocephalus required a revision procedure. Leak etiologies included prior craniotomy for frontal sinus mucopyocele, spontaneous meningoencephalocele, erosion due to mucormycosis, and prior endoscopic sinus surgery. The frontal sinus remained patent in three of four patients. No patients have evidence of a leak at a minimum of 1 year after surgery. The repair of frontal sinus CSF leaks is possible in specific cases with an endoscopic unilateral approach in leaks with multiple etiologies. Surgeons should consider this approach when selecting the appropriate procedure for repair of frontal sinus CSF leaks.

A systematic review of the endoscopic repair of cerebrospinal fluid leaks

OBJECTIVES

To provide an up-to-date review of the literature on the safety and efficacy of the endoscopic technique for cerebrospinal (CSF) leak repairs.

DATA SOURCES

PubMed, Medline/Old Medline, and Cochrane Central databases.

REVIEW METHODS

Using the above outlined data sources, studies involving the endoscopic repair of CSF leaks were reviewed independently by 2 researchers. Studies included met the following criteria: full-text article written in the English language, at least 5 human patients undergoing purely endoscopic surgical repair of a CSF leak, and documented follow-up. Data extracted included leak etiology, presentation and location, the use of imaging, intrathecal fluorescein, and adjunctive measures as well as the success rate of the repair.

RESULTS

Fifty-five studies, involving 1778 fistulae repairs, were included for analysis. Spontaneous leaks were most prevalent, with the ethmoid roof and sphenoid the most common sites involved. The overall success rate of repair was high at 90% for primary and 97% for secondary repairs. A low complication rate of less than 0.03% was reported.

CONCLUSION

The endoscopic repair of CSF fistula is both safe and effective and should be considered the standard of care for most cases. Evidence supporting adjunctive measures such as lumbar drains and antibiotics remains limited despite their common use.

Juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibromas (JNAs) are rare, benign, highly vascular, locally aggressive tumors that primarily affect male adolescents. Historical treatment of these neoplasms has been primarily surgical. In the past decade, endoscopic resection of JNAs has become a viable and promising surgical treatment option. Endoscopic resection has many advantages over traditional open techniques, including better cosmesis, decreased blood loss, shortened hospital stays, and equivalent or improved recurrence rates. Emerging endoscopic technology continues to push the boundaries of resection of skull base tumors and will no doubt become the surgical treatment of choice for most JNAs in the near future.

Changing paradigms in frontal sinus cerebrospinal fluid leak repair

BACKGROUND

Frontal sinus cerebrospinal fluid (CSF) leaks have traditionally been repaired via open procedures (eg, osteoplastic flap or cranialization). Advancements in instrumentation, technique, and experience have improved the feasibility of repairing frontal sinus skull-base defects using an endoscopic approach. This study describes endoscopic closure of frontal sinus CSF leaks focusing on management, surgical technique, and outcomes.

METHODS

Prospective evaluation of patients with skull-base defects involving the frontal sinus was performed. Demographics, size of skull-base defect, length involving the posterior table, successful closure, frontal sinus patency, and complications were recorded.

RESULTS

Over 3.5 years, 37 patients (average age 46 years) were treated for CSF leaks involving the frontal sinus by a single otolaryngologist. Etiologies included spontaneous (13), tumor (13), and trauma (11). Average defect size (length vs width) was 16.9 mm × 10.7 mm and average length involving the posterior table was 6.9 mm (range, 1-30 mm). Success rate on first attempt was 91.9% (34/37), but improved to 97.3% on subsequent endoscopic revision. One patient required a cranialization. The average follow-up was 48 weeks. The nasoseptal flap was used for reconstruction in 27 patients. A Draf III procedure (ie, bilateral resection of the frontal sinus floor) was required in 14 subjects. Three patients were referred as a result of unsuccessful closure following cranializations; their CSF leaks were successfully repaired using endoscopic approaches. Two individuals required a subsequent endoscopic frontal sinus procedure, but have maintained long-term patency following revision.

CONCLUSION

Frontal sinus CSF leaks were successfully closed in 97.3% of individuals. Our data supports the routine use of endoscopic repair in the treatment algorithm for frontal sinus skull-base defects.

The Draf III Mucosal Grafting Technique

Objective. The Draf III procedure is an advanced surgical option for frontal sinus disease refractory to endoscopic frontal sinusotomy and is used to expose the anterior limit of resection of the skull base during endoscopic management of anterior skull base tumors. Our objective was to evaluate outcomes of a strategy using mucosal grafts to decrease postoperative closure.

Study Design. Prospective cohort.

Setting. Tertiary care facility.

Subjects and Methods. Patients requiring a Draf III procedure were prospectively enrolled in the study. Demographics, reason for the procedure, percentage graft viability, and complications were recorded. The primary outcome measure was anterior-posterior (AP) diameter at 3 months.

Results. Mucosal grafting was performed during 29 Draf III procedures from 2008 to 2011. Twenty-seven patients (average age, 58 years) were available for measurement at 3 months (average postoperative follow-up, 15.4 months; range, 3–30 months). Reasons for the procedure included tumor (n = 14), chronic rhinosinusitis (CRS) with frontal ostium stenosis (n = 12), and trauma (n = 1). Average intraoperative AP diameter was 11.7 mm. All patients met the definition of success (<50% reduction in diameter), maintaining a patent combined frontal sinus ostium for the duration of follow-up (average diameter 10.8 mm at 3 months). Nine patients with CRS and frontal ostium stenosis had openings similar to the entire cohort (>1-year follow-up; average, 19.3 months) with significant symptom reduction (SNOT-22 preop 62.3 ± 20.8 vs 3 months 27.8 ± 14.8 and 1 year 21.4 ± 13.6; P < .0001).

Conclusion. Cicatricial stenosis and osteoneogenesis are common following the Draf III procedure. This study indicates that the use of mucosal grafts may assist with postoperative stenosis and should be considered a routine strategy for preventing closure.

Treatment outcomes of endoscopic repairs of sinonasal cerebrospinal fluid leaks

OBJECTIVE

The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base.

MATERIALS AND METHODS

A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009.

RESULTS

The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted.

CONCLUSIONS

Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.

Lateral frontal sinus access in endoscopic skull-base surgery

BACKGROUND

The modified endoscopic Lothrop (MELP) or Draf III procedure can provide extended endoscopic access to the frontal sinus. The ability to access the entire frontal sinus entirely endoscopically is often debated and there is little published data to predict access based on tumor location.

METHODS

MELP was performed in 10 cadaver heads. Access was defined as the ability to contact the bone under vision with the head of a 70-degree diamond burr. Access was assessed in 3 areas: the orbital roof and the anterior and posterior walls of the frontal sinus. Endpoints were defined in millimeters from medial orbit and lateral quartile zones.

RESULTS

Complete lateral access was excellent anterior and posterior in 95% of sinuses (mean 15.5 ± 7.8 mm and 15.4 ± 7.7 mm, respectively). Access to the orbital roof was limited (10.3 ± 4.6 mm; p = 0.01 comparing anterior and posterior). For sinuses pneumatized beyond the midorbital point, only 10% of lateral orbital roofs were contacted. Orbital roof access correlated with the anteroposterior (AP) distance between the olfactory fossa and outer periosteum of the frontal beak (r = 0.6, p < 0.01).

CONCLUSION

Lateral endoscopic access to the walls of the frontal sinus is excellent except for the sinus floor. Access to the orbital roof is reliable in the medial quarter only and minimal lateral to the midorbital point. The ability to predict the areas accessible by the endoscopic approach and those areas that might require ancillary approaches is important for both surgical planning and patient expectations.

Evolving materials and techniques for endoscopic sinus surgery

Functional endoscopic sinus surgery was initially introduced as a minimally invasive procedure to treat chronic rhinosinusitis (CRS) in patients for whom medical management failed. Sinus surgery has been deemed an extremely effective part of the overall management of chronic sinus disease with symptomatic improvement in the vast majority of patients. At the forefront, technologic advances have been critical in advancing endoscopic sinus surgical procedures. With the introduction of improved optics and lighting, advanced instrumentation, and image-guided surgical navigation, the limitations of endoscopic procedures have been significantly reduced. Endoscopic techniques have evolved to include the management of both malignant and benign neoplasms of the sinuses and anterior skull base. This article highlights some of the newest advances in technology, materials, and medical/surgical techniques used in endoscopic sinus and skull base procedures and illustrates how they advance overall patient care to help minimize morbidity and complications.

Surgical management of benign sinonasal masses

A diverse group of pathologic findings requires surgical excision from the sinonasal tract. Symptoms directly related to pathologic findings, pending complications and the possibility or suspicion of malignancy, should be the cornerstones of surgical decision making. The management of benign sinonasal masses should follow a balanced algorithm to weigh the need for resection against the adverse effects of surgical removal. Endoscopic approaches have become the primary modality by which most benign masses of the nasal cavity and sinuses are managed. This article describes an aggressive surgical approach to these lesions while maintaining respect for their benign nature and the importance of preserving natural barriers to growth (spread), such as the dura and periorbita.

Localization and infliction pattern of iatrogenic skull base defects following endoscopic sinus surgery at a teaching hospital

OBJECTIVE

Aim of this study is to evaluate the incidence, infliction patterns and management of dural injuries with cerebrospinal fluid (CSF) rhinorrhea following endoscopic sinus surgery at a teaching hospital. We present our results of over 14 years of experience from endoscopic repair of CSF rhinorrhea with long-term follow-up.

METHODS

A retrospective study was performed by screening 14 years of sinus surgeries for iatrogenically inflicted CSF leaks of the anterior skull base. Obtained data were analyzed to determine the infliction pattern and location of CSF leaks, surgical closure techniques and outcomes. All incidences were further evaluated with regards to the surgeons training status.

RESULTS

144 patients out of 6908 sinus surgeries were diagnosed with CSF rhinorrhea and underwent subsequent surgical repair. 52 patients had iatrogenic CSF leaks with 32 of the defects inflicted by the department's physician personnel. Average follow-up was 62 months, with a range of 10-168 months. The side distribution was 56.3% to the patient's right side and in 40.6% to the patient's left side. 68.7% became apparent during the initial surgery whereas 31.3% only after surgery. The most common defect location was the anterior ethmoid at the attachment of the medial concha base with 43.7%, followed by the junction between the ethmoid and sphenoid sinus with 21.9%, the frontal sinus aditus with 18.7% and the medial ethmoid region with 9.4%. With increasing training status, surgeons were more prone to cause defects at the frontal sinus aditus whereas surgeons with lesser training status caused more defects at the anterior ethmoid at the medial concha base. The posterior ethmoid and sphenoid sinus was equally prone to defects over all stages of surgical training. Initial endoscopic repair was successful in 87.5% of patients and 95% after revision surgery.

CONCLUSION

The obtained data confirm the safety of the endonasal sinus surgery according to Wigand's technique. The incidence of iatrogenic CSF leaks at a teaching hospital is not higher than at specialized rhinology departments. We observed a distinct pattern of inflicted skull base defects with different hot-spot areas, prone to damage in various stages of the surgeon's status of expertise.