Tissue Sealant Impact on Skull Base Reconstruction Outcomes: A Systematic Review and Meta-Analysis

OBJECTIVE

Despite significant advances in understanding of skull base reconstruction principles, the role of tissue sealants in modifying postoperative cerebrospinal fluid (CSF) leak outcomes remains controversial. We evaluate postoperative CSF leak incidence associated with tissue sealant use in skull base defect repair during endoscopic skull base surgery (ESBS).

DATA SOURCES

Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library.

REVIEW METHODS

Systematic review and meta-analysis of risk differences (RD). A search strategy identified original studies reporting CSF leakage following ESBS with disaggregation by tissue sealant use and/or type.

RESULTS

27 non-randomized studies (n = 2,403) were included for qualitative and meta-analysis. Reconstruction with a tissue sealant did not significantly reduce postoperative CSF leak risk compared with reconstruction without sealant (RD[95% CI] = 0.02[-0.01, 0.05]). Sub-analyses of dural sealant (-0.02[-0.11, 0.07]) and fibrin glue (0.00[-0.07, 0.07]) compared with no sealant were similarly unremarkable. Postoperative CSF leakage was not significantly modulated in further sub-analyses of DuraSeal (0.02[-0.02, 0.05]), Adherus (-0.03[-0.08, 0.03]), or Bioglue (-0.06[-0.23, 0.12]) versus no dural sealant use, or Tisseel/Tissucol versus fibrin glue nonuse (0.00[-0.05, 0.05]). No significant association was seen comparing dural sealant use versus fibrin glue use on pairwise (0.01[-0.03, 0.05]) or network meta-analysis (-0.01[-0.05, 0.04]). Limitations in source literature prevented sub-analyses stratified by leak characteristics, defect size and location, and accompanying reconstruction materials.

CONCLUSION

Tissue sealant use did not appear to impact postoperative CSF leak incidence when compared with nonuse. Higher quality studies are warranted to thoroughly elucidate the clinical value of adjunct sealant use in endoscopic skull base reconstruction.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:3425-3436, 2024.

Arthroscopic management of synovial chondromatosis with skull base perforation: A case report and literature review

OBJECTIVE

Synovial chondromatosis (SC) of the temporomandibular joint (TMJ) is a synovial membrane disease characterized by the formation of cartilaginous nodules (CN), that may erode the skull base. Historically, cases with skull base involvement have been treated with open surgery. We report a case of TMJ SC with skull base perforation treated and repaired via minimally invasive TMJ arthroscopy and describe the advanced endoscopic operative maneuvers performed.

CASE REPORT

A 34-year-old male presented with a 4-year history of malocclusion and right TMJ arthralgia. Clinical examination demonstrated malocclusion and direct pressure loading pain. Advanced imaging revealed glenoid fossa erosion and numerous homogenous hypointense lesions within an effusion. The initial surgical plan included diagnostic TMJ arthroscopy followed by conversion to open arthroplasty. Endoscopic operative maneuvers allowed for the accomplishment of the surgical goals, completely arthroscopically. Histopathology confirmed SC, and the patient remains on observation, with relief of symptoms.

CONCLUSION

Advanced arthroscopy is a viable treatment option for select cases of TMJ SC with skull base involvement that allowed for access to the joint space, retrieval of biopsy specimens and CN, and repair of the skull defect.

Management of coexistent sinonasal pathology in patients undergoing endoscopic cerebrospinal fluid rhinorrhea repair

Introduction

Patients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair.

Objective

To study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea

Methods

A retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period.

Results

Of a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%).

Conclusion

Patients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.

Role of diffusion-weighted imaging in the discrimination of purulent intrasinusal content: A retrospective study

OBJECTIVES

The objective of this study was to analyse MRI with morphological (T1, T2) and diffusion sequences (DWI, b1000) in patients presenting non-aggressive patterns of sinus opacity and operated on by functional endoscopic sinus surgery (FESS).

DESIGN

A retrospective study.

SETTING

Diffusion imaging in paranasal sinus pathology remains little known. To date, no imaging system is capable of determining the purulent content of a non-enhanced sinus filling.

PARTICIPANTS

We included consecutive patients having undergone FESS in whom MRI of the paranasal sinuses was performed. Subjects were allocated to Case (pus) or Control (no pus) groups depending on sinus content found intraoperatively. FESS was performed for bacterial acute rhinosinusitis, acute exacerbations of chronic rhinosinusitis, non-purulent sinusitis, naso-sinusal polyposis, antrochoanal polyp, isolated polyp, angiomatous polyp and eosinophilic fungal sinusitis. Tumours, mucoceles and fungus balls were excluded.

MAIN OUTCOME MEASURES

We analysed T1, T2, b1000 and MRI sequences and ADC map.

RESULTS

On univariate analysis, intermediate signal in T2 and high signal in b1000 were associated with Cases (P < 0.001) as were low ADC values (P < 0.001). The difference in mean ADC values between Cases and Controls was statistically significant (respectively, 0.518 vs 2.041 × 10^-3  mm² /sec, P < 0.01). On multivariate analysis, MRI with ADC < 0.725 × 10^-3  mm² /sec and b1000_SI > brain was significantly associated with the case group. MRI with b1000_SI < brain and ADC > 1.450 × 10^-3  mm² /sec was significantly associated with the control group.

CONCLUSIONS

Diffusion MRI offers extremely promising results regarding content characterisation of infectious sinus diseases.

Spontaneous nasal cerebrospinal fluid leaks: management of 24 patients over 11 years

PURPOSE

Most cases of non-traumatic nasal cerebrospinal fluid (CSF) leaks occur spontaneously without any obvious reason. Severe and life-threatening complications are possible consequences. Endoscopic repair is considered the gold standard; however, diagnosis and therapy of these CSF leaks stay challenging.

METHODS

In this retrospective analysis, patients who presented with spontaneous nasal CSF leaks from 2006 to 2017 were included. Symptoms, diagnostics, localization of the skull base defect, surgical method, outcome, and postoperative treatment were recorded.

RESULTS

Twenty four patients were included. 8 patients presented with symptoms of meningitis. The skull base defects were most commonly located in the anterior ethmoid roof-especially in the cribriform plate-and in the lateral part of the sphenoid sinus. 21 patients had a BMI above 25. In only 13 cases the defect could be detected preoperatively via computed tomography or additional magnetic resonance imaging. In all patients intraoperative visualization of the CSF leak was possible using intrathecal application of sodium-fluorescein. Endoscopic repair was the initial surgical method for all patients and proved to be successful in 80% of the cases. In most cases surgical revision was performed endoscopically; however, in two patients an open transpterygoidal approach was necessary.

CONCLUSIONS

Spontaneous nasal CSF leaks often initially present with symptomatic meningitis. Imaging does not always clearly identify the skull base defect. Common localizations are the anterior ethmoid roof and the lateral sphenoid sinus. Obesity seems to be a predisposing factor. In most cases, endoscopic repair with low morbidity is possible; however, an individualized approach is necessary.