Skip to main content
PMC home page
Skull Base logoLink to Skull Base
. 2001;11(1):47–58. doi: 10.1055/s-2001-12787

Endonasal Endoscopic Closure of Cerebrospinal Fluid Rhinorrhea

S Schmerber, Ch Righini, J-P Lavielle, J-G Passagia, E Reyt
PMCID: PMC1656831  PMID: 17167603

Abstract

The authors review their experience with endoscopic repair of skull base defects associated with cerebrospinal fluid (CSF) rhinorrhea involving the paranasal sinuses. A total of 22 patients was treated endoscopically between 1992 and 1998. The repair method consisted of closure of the CSF fistula with a free autologous abdominal fat graft and fibrin glue, supported with a sheet of silastic. The primary closure rate was 82% (18/22), and the overall closure rate was 95.5% (21/22) without recurrence or complications within an average follow-up of 5 years (14-83 months). A single patient still complains of cerebrospinal rhinorrhea, although this was never proved by any clinical, endoscopic, or biological (β2-transferrin) examination. The repair of ethmoidal-sphenoidal cerebrospinal fluid fistulae by endonasal endoscopic surgery is an excellent technique, both safe and effective. Fat is a material of choice, as it is tight and resists infection well. The technique and indications for endoscopic management of cerebrospinal fluid leaks are discussed.

Keywords: Cerebrospinal fluid rhinorrhea, fat graft, endoscopic treatment, anterior cranial fossa, ethmoid, sphenoidal sinus, MRI cisternography

Full text

PDF
49

Images in this article

48Figure 1
on p.48
49Figure 2
on p.49
50Figure 3
on p.50
53Figure 4
on p.53
54Figure 5
on p.54

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Antimicrobial prophylaxis in neurosurgery and after head injury. Infection in Neurosurgery Working Party of the British Society for Antimicrobial Chemotherapy. Lancet. 1994 Dec 3;344(8936):1547–1551. [PubMed] [Google Scholar]
  2. Blennow K., Fredman P. Detection of cerebrospinal fluid leakage by isoelectric focusing on polyacrylamide gels with silver staining using the PhastSystem. Acta Neurochir (Wien) 1995;136(3-4):135–139. doi: 10.1007/BF01410615. [DOI] [PubMed] [Google Scholar]
  3. Brunon J., Duthel R., Motuo-Fotso M. J., Huppert J. Rhinorrhée spontanée révélatrice d'une méningoencéphalocèle intranasale et d'un épendymome du IVe ventricule. Neurochirurgie. 1990;36(6):383–387. [PubMed] [Google Scholar]
  4. Burns J. A., Dodson E. E., Gross C. W. Transnasal endoscopic repair of cranionasal fistulae: a refined technique with long-term follow-up. Laryngoscope. 1996 Sep;106(9 Pt 1):1080–1083. doi: 10.1097/00005537-199609000-00007. [DOI] [PubMed] [Google Scholar]
  5. CROW H. J., KEOGH C., NORTHFIELD D. W. The localisation of cerebrospinal-fluid fistulae. Lancet. 1956 Aug 18;271(6938):325–327. doi: 10.1016/s0140-6736(56)92188-2. [DOI] [PubMed] [Google Scholar]
  6. Calcaterra T. C. Extracranial surgical repair of cerebrospinal rhinorrhea. Ann Otol Rhinol Laryngol. 1980 Mar-Apr;89(2 Pt 1):108–116. doi: 10.1177/000348948008900202. [DOI] [PubMed] [Google Scholar]
  7. Charles D. A., Snell D. Cerebrospinal fluid rhinorrhea. Laryngoscope. 1979 May;89(5 Pt 1):822–826. doi: 10.1288/00005537-197905000-00021. [DOI] [PubMed] [Google Scholar]
  8. Colquhoun I. R. CT cisternography in the investigation of cerebrospinal fluid rhinorrhoea. Clin Radiol. 1993 Jun;47(6):403–408. doi: 10.1016/s0009-9260(05)81061-x. [DOI] [PubMed] [Google Scholar]
  9. Curnes J. T., Vincent L. M., Kowalsky R. J., McCartney W. H., Staab E. V. CSF rhinorrhea: detection and localization using overpressure cisternography with Tc-99m-DTPA. Radiology. 1985 Mar;154(3):795–799. doi: 10.1148/radiology.154.3.3881800. [DOI] [PubMed] [Google Scholar]
  10. De Tovar G., Akerman M., Jedynak C. P., Derome P. La cisternographie isotopique hyperbare pour la recherche des fuites de liquide céphalo-rachidien. Nouv Presse Med. 1976 May 29;5(22):1433–1433. [PubMed] [Google Scholar]
  11. Dodson E. E., Gross C. W., Swerdloff J. L., Gustafson L. M. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. Otolaryngol Head Neck Surg. 1994 Nov;111(5):600–605. doi: 10.1177/019459989411100510. [DOI] [PubMed] [Google Scholar]
  12. Drayer B. P., Wilkins R. H., Boehnke M., Horton J. A., Rosenbaum A. E. Cerebrospinal fluid rhinorrhea demonstrated by metrizamide CT cisternography. AJR Am J Roentgenol. 1977 Jul;129(1):149–151. doi: 10.2214/ajr.129.1.149. [DOI] [PubMed] [Google Scholar]
  13. El Gammal T., Sobol W., Wadlington V. R., Sillers M. J., Crews C., Fisher W. S., 3rd, Lee J. Y. Cerebrospinal fluid fistula: detection with MR cisternography. AJNR Am J Neuroradiol. 1998 Apr;19(4):627–631. [PMC free article] [PubMed] [Google Scholar]
  14. Eljamel M. S., Pidgeon C. N. Localization of inactive cerebrospinal fluid fistulas. J Neurosurg. 1995 Nov;83(5):795–798. doi: 10.3171/jns.1995.83.5.0795. [DOI] [PubMed] [Google Scholar]
  15. Eljamel M. S., Pidgeon C. N., Toland J., Phillips J. B., O'Dwyer A. A. MRI cisternography, and the localization of CSF fistulae. Br J Neurosurg. 1994;8(4):433–437. doi: 10.3109/02688699408995111. [DOI] [PubMed] [Google Scholar]
  16. Findler G., Sahar A., Beller A. J. Continuous lumbar drainage of cerebrospinal fluid in neurosurgical patients. Surg Neurol. 1977 Dec;8(6):455–457. [PubMed] [Google Scholar]
  17. Gacek R. R., Gacek M. R., Tart R. Adult spontaneous cerebrospinal fluid otorrhea: diagnosis and management. Am J Otol. 1999 Nov;20(6):770–776. [PubMed] [Google Scholar]
  18. Gates G. A., Sertl G. O., Grubb R. L., Wippold F. J., 2nd Closure of clival cerebrospinal fluid fistula with biocompatible osteoconductive polymer. Arch Otolaryngol Head Neck Surg. 1994 Apr;120(4):459–461. doi: 10.1001/archotol.1994.01880280087017. [DOI] [PubMed] [Google Scholar]
  19. Gjuric M., Goede U., Keimer H., Wigand M. E. Endonasal endoscopic closure of cerebrospinal fluid fistulas at the anterior cranial base. Ann Otol Rhinol Laryngol. 1996 Aug;105(8):620–623. doi: 10.1177/000348949610500806. [DOI] [PubMed] [Google Scholar]
  20. Gupta V., Goyal M., Mishra N., Gaikwad S., Sharma A. MR evaluation of CSF fistulae. Acta Radiol. 1997 Jul;38(4 Pt 1):603–609. doi: 10.1080/02841859709174393. [DOI] [PubMed] [Google Scholar]
  21. Hughes R. G., Jones N. S., Robertson I. J. The endoscopic treatment of cerebrospinal fluid rhinorrhoea: the Nottingham experience. J Laryngol Otol. 1997 Feb;111(2):125–128. doi: 10.1017/s0022215100136643. [DOI] [PubMed] [Google Scholar]
  22. Irjala K., Suonpä J., Laurent B. Identification of CSF leakage by immunofixation. Arch Otolaryngol. 1979 Aug;105(8):447–448. doi: 10.1001/archotol.1979.00790200009002. [DOI] [PubMed] [Google Scholar]
  23. Johnson D. B., Brennan P., Toland J., O'Dwyer A. J. Magnetic resonance imaging in the evaluation of cerebrospinal fluid fistulae. Clin Radiol. 1996 Dec;51(12):837–841. doi: 10.1016/s0009-9260(96)80079-1. [DOI] [PubMed] [Google Scholar]
  24. KIRCHNER F. R., PROUD G. O. Method for the identification and localization of cerebrospinal fluid, rhinorrhea and otorrhea. Laryngoscope. 1960 Jul;70:921–931. doi: 10.1288/00005537-196007000-00004. [DOI] [PubMed] [Google Scholar]
  25. Kosoy J., Trieff N. M., Winkelmann P., Bailey B. J. Glucose in nasal secretions. Diagnostic significance. Arch Otolaryngol. 1972 Mar;95(3):225–229. doi: 10.1001/archotol.1972.00770080367008. [DOI] [PubMed] [Google Scholar]
  26. Lanza D. C., O'Brien D. A., Kennedy D. W. Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles. Laryngoscope. 1996 Sep;106(9 Pt 1):1119–1125. doi: 10.1097/00005537-199609000-00015. [DOI] [PubMed] [Google Scholar]
  27. Levy L. M., Gulya A. J., Davis S. W., LeBihan D., Rajan S. S., Schellinger D. Flow-sensitive magnetic resonance imaging in the evaluation of cerebrospinal fluid leaks. Am J Otol. 1995 Sep;16(5):591–596. [PubMed] [Google Scholar]
  28. Mattox D. E., Kennedy D. W. Endoscopic management of cerebrospinal fluid leaks and cephaloceles. Laryngoscope. 1990 Aug;100(8):857–862. doi: 10.1288/00005537-199008000-00012. [DOI] [PubMed] [Google Scholar]
  29. Messerklinger W. Nasenendoskopie: Nachweis, Lokalisation und Differentialdiagnose der nasalen Liquorrhoe. HNO. 1972 Sep;20(9):268–270. [PubMed] [Google Scholar]
  30. Middelweerd M. J., de Vries N., Calliauw J., van Kamp G. J. A new biochemical assay in the diagnostic management of nasal cerebrospinal fluid leakage. Eur Arch Otorhinolaryngol. 1995;252(6):336–339. doi: 10.1007/BF00178272. [DOI] [PubMed] [Google Scholar]
  31. Nguyen A., Pasyk K. A., Bouvier T. N., Hassett C. A., Argenta L. C. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg. 1990 Mar;85(3):378–389. [PubMed] [Google Scholar]
  32. Nicklaus P., Dutcher P. O., Kido D. K., Hengerer A. S., Nelson C. N. New imaging techniques in diagnosis of cerebrospinal fluid fistula. Laryngoscope. 1988 Oct;98(10):1065–1068. doi: 10.1288/00005537-198810000-00008. [DOI] [PubMed] [Google Scholar]
  33. OMMAYA A. K. CEREBROSPINAL FLUID RHINORRHEA. Neurology. 1964 Feb;14:106–113. doi: 10.1212/wnl.14.2.106. [DOI] [PubMed] [Google Scholar]
  34. Oberascher G. A modern concept of cerebrospinal fluid diagnosis in oto- and rhinorrhea. Rhinology. 1988 Jun;26(2):89–103. [PubMed] [Google Scholar]
  35. Ohnishi T. Bony defects and dehiscences of the roof of the ethmoid cells. Rhinology. 1981 Dec;19(4):195–202. [PubMed] [Google Scholar]
  36. Papay F. A., Maggiano H., Dominquez S., Hassenbusch S. J., Levine H. L., Lavertu P. Rigid endoscopic repair of paranasal sinus cerebrospinal fluid fistulas. Laryngoscope. 1989 Nov;99(11):1195–1201. doi: 10.1288/00005537-198911000-00018. [DOI] [PubMed] [Google Scholar]
  37. Saccogna P. W., Werning J. W., Setrakian S., Strauss M. Lipoinjection in the paralyzed feline vocal fold: study of graft survival. Otolaryngol Head Neck Surg. 1997 Nov;117(5):465–470. doi: 10.1016/S0194-59989770015-9. [DOI] [PubMed] [Google Scholar]
  38. Shapiro S. A., Scully T. Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula. Neurosurgery. 1992 Feb;30(2):241–245. doi: 10.1227/00006123-199202000-00015. [DOI] [PubMed] [Google Scholar]
  39. Shetty P. G., Shroff M. M., Sahani D. V., Kirtane M. V. Evaluation of high-resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula. AJNR Am J Neuroradiol. 1998 Apr;19(4):633–639. [PMC free article] [PubMed] [Google Scholar]
  40. Skedros D. G., Cass S. P., Hirsch B. E., Kelly R. H. Sources of error in use of beta-2 transferrin analysis for diagnosing perilymphatic and cerebral spinal fluid leaks. Otolaryngol Head Neck Surg. 1993 Nov;109(5):861–864. doi: 10.1177/019459989310900514. [DOI] [PubMed] [Google Scholar]
  41. Stankiewicz J. A. Cerebrospinal fluid fistula and endoscopic sinus surgery. Laryngoscope. 1991 Mar;101(3):250–256. doi: 10.1288/00005537-199103000-00006. [DOI] [PubMed] [Google Scholar]
  42. Stankiewicz J. A. Complications in endoscopic intranasal ethmoidectomy: an update. Laryngoscope. 1989 Jul;99(7 Pt 1):686–690. doi: 10.1288/00005537-198907000-00004. [DOI] [PubMed] [Google Scholar]
  43. Stankiewicz J. A. The endoscopic approach to the sphenoid sinus. Laryngoscope. 1989 Feb;99(2):218–221. doi: 10.1288/00005537-198902000-00016. [DOI] [PubMed] [Google Scholar]
  44. Wakhloo A. K., van Velthoven V., Schumacher M., Krauss J. K. Evaluation of MR imaging, digital subtraction cisternography, and CT cisternography in diagnosing CSF fistula. Acta Neurochir (Wien) 1991;111(3-4):119–127. doi: 10.1007/BF01400499. [DOI] [PubMed] [Google Scholar]
  45. Wax M. K., Ramadan H. H., Ortiz O., Wetmore S. J. Contemporary management of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg. 1997 Apr;116(4):442–449. doi: 10.1016/S0194-59989770292-4. [DOI] [PubMed] [Google Scholar]
  46. Wetmore S. J. Injection of fat for soft tissue augmentation. Laryngoscope. 1989 Jan;99(1):50–57. doi: 10.1288/00005537-198901000-00010. [DOI] [PubMed] [Google Scholar]
  47. Wigand M. E., Hosemann W. G. Results of endoscopic surgery of the paranasal sinuses and anterior skull base. J Otolaryngol. 1991 Dec;20(6):385–390. [PubMed] [Google Scholar]
  48. Wigand M. E. Transnasal ethmoidectomy under endoscopical control. Rhinology. 1981 Mar;19(1):7–15. [PubMed] [Google Scholar]

Articles from Skull Base are provided here courtesy of Thieme Medical Publishers

RESOURCES