Endoscopic repair of CSF rhinorrhoea: A review of its efficacy and success rate

Hemalatha, K (2016) Endoscopic repair of CSF rhinorrhoea: A review of its efficacy and success rate. Masters thesis, Madras Medical College, Chennai.


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BACKGROUND: CSF rhinorrhoea occurs due to a trans dural communication between the nasal cavity and the subarachnoid space. Its repair has been revolutionized by the advent of much easier endoscopic repair techniques which cause lesser morbidity as compared to open surgical techniques with regard to the CSF leak sites under study. This study strives to elucidate the outcomes obtained through endoscopic approach and also our experience obtained, during the management, through our patients under study. INTRODUCTION: Duramater of the brain is an important barrier for any infection to ascend intracranially. It contains the cerebrospinal fluid present within the subarachnoid space and hence, a transdural event can cause breach in its integrity causing leak of the cerebrospinal fluid, as evident from watery nasal discharge. CSF rhinorrhoea ensues when the breach involves the nasal mucosa, periosteum, bone forming the skull base in the region of nose and paranasal sinuses, endosteum, duramater and arachnoidmater. Transdural event can be due to trauma, nasal surgery, tumors invading skull base or may be spontaneous. In each of these cases, the outcome is the same- CSF leak from the site of injury to dura and ascending infection through the defect causing meningitis and related complications. In cases where the medical therapy fails, it is mandatory for surgical closure to prevent such complications. Surgical repair of CSF leak site can be either through an intracranial or an extracranial approach. Endoscopic approach is a type of extracranial approach which has the advantage of being less invasive, no external surgical scar, excellent site localization with preservation of the surrounding anatomy and shorter hospital stay. Unlike open surgical techniques, endoscopic approach avoids excessive mobilization of the brain and the dura and, offers wide and site specific view through a smaller exposure than that achieved through a microscope. AIM OF THE STUDY: 1. To study the common sites of CSF leak. 2. To evaluate the efficacy of endoscopic CSF leak repair. 3. To study various methods of skull base defect closure used in endoscopic repair of CSF rhinorrhoea. INCLUSION CRITERIA: 1. Anterior and middle cranial fossa easily approached endoscopically. 2. Size of defect- small size defect as determined using direct endoscopic visualization and radiological evaluation. 3. Etiology- traumatic, iatrogenic, spontaneous and tumorrelated CSF leaks. 4. Precise defect that can be localized. 5. Failure of conservative management. EXCLUSION CRITERIA: 1. Defect not localized by radiological and other CSF leak studies. 2. Multiple injuries requiring intracranial approach. 3. Pneumocephalous. MATERIALS AND METHODS: The study included 22 patients with CSF rhinorrhoea arising from the anterior and midde cranial fossa not subsiding with medical management .It is a prospective study done during the period of 2013 to 2015 in, The Upgraded Institute of Otorhinolaryngology, Madras Medical College, Chennai. All the patients were evaluated for CSF rhinorrhoea using a battery of tests which involves the clinical examination for the reservoir sign, biochemical and microbiological analysis of the fluid, radiological investigations and diagnostic nasal endoscopy to assess the site of leak. All patients were treated in a multidiscilplinary approach. We worked in co-ordination with the neurosurgery department of our Institute in evaluating and treating patients with traumatic history. Some of them needed a neurosurgical intervention for head injury and were managed medically for CSF rhinorrhoea. Patients who did not respond to the medical management and had a size of defect less than 2 cm were taken up for our study. In cases of spontaneous CSF rhinorrhoea, we worked in coordination with the neurologist to rule out intracranial causes for a raised CSF pressure and all patients were evaluated by ophthalmologist to rule out benign intracranial hypertension as a cause of CSF rhinorrhoea. This multidisciplinary approach guided us to decide upon further evaluation of a raised intracranial pressure if present and, to plan for the placement of lumbar drain .We evaluated the demographic data, CSF leak site and size, etiology, complications, surgical closure techniques, complications of surgery and recurrences and its management. CONCLUSION: We conclude that, in our study, the most common site of leak associated with spontaneous etiology is cribriform plate (31.8%) and frontal sinus leak is seen more with traumatic etiology (22.7%). The method of closure may vary. But, the identification of the leak site and the plane between dura and the bone around the defect is important determinant of the success rather than the choice of material. For most of these cases, fat was used as the first layer of underlay technique which acts as a good seal. Additional procedures such as pedicled nasoseptal flap, rotation of middle turbinate, septal cartilage augmentation were used in larger defects of about 6 mm or more. The efficacy of endoscopic CSF leak closure in our study was 95.45%.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Endoscopic repair ; CSF Rhinorrhoea.
Subjects: MEDICAL > Otolaryngology
Depositing User: Punitha K
Date Deposited: 01 Aug 2017 09:49
Last Modified: 22 Dec 2018 12:13
URI: http://repository-tnmgrmu.ac.in/id/eprint/2428

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