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endoscopic CSF rhinorrhea


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endoscopic CSF rhinorrhea

  1. 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