Abstract
Purpose
Persistent cerebrospinal fluid (CSF) rhinorrhea after open skull base surgery can be challenging to manage due to the risk of meningitis, brain abscess, surgical morbidity associated with revision craniotomy, and the lack of available healthy autologous tissue after failure of a pericranial flap. Given the recent success of the vascularized pedicled nasoseptal flap (PNSF) for reconstruction after endoscopic skull base surgery, we have adopted this technique as a salvage method to treat recalcitrant CSF rhinorrhea after previous open skull base surgery in order to avoid revision craniotomy. To our knowledge, use of the PNSF in this setting has not been previously described in the literature.
Methods
A retrospective analysis was performed on 4 patients who underwent endoscopic endonasal PNSF repair of persistent CSF rhinorrhea after having undergone previous open transcranial skull base operation. Pathologies consisted of one sinonasal anterior skull base squamous cell carcinoma, one recurrent petrosal skull base meningioma, and 2 traumatic gunshot wounds to the head.
Results
All 4 patients underwent successful repair of CSF rhinorrhea without complications using the salvage endoscopic endonasal PNSF technique after a mean follow-up of 21.5 months.
Conclusions
In patients who have undergone previous open skull base surgery as the primary approach, persistent CSF rhinorrhea can be safely repaired using the vascularized PNSF via an endoscopic endonasal approach. This minimally invasive strategy has the advantage of providing new healthy vascularized tissue for skull base reconstruction while avoiding revision craniotomy.
1
Introduction
Cerebrospinal fluid (CSF) rhinorrhea occurs when there is a fistula between the dura and the skull base resulting in drainage of CSF from the nose. The etiology of CSF rhinorrhea can be divided into traumatic and nontraumatic causes. Within the traumatic cases, iatrogenic cranial base surgery is one of the most common culprits .
The first documented attempt at repairing a CSF leak was made by Dandy in 1926 through a bifrontal craniotomy . This approach has remained the gold standard until more recently with advances in endoscopic sinus and skull base surgery. Transcranial approaches for repair of CSF rhinorrhea can be associated with some morbidity including cerebral contusion, intracranial hemorrhage, cerebral edema, anosmia, pneumocephalus, bifrontal retraction injury, venous infarction, and bone flap infection . Revision craniotomy for persistent CSF rhinorrhea can also be challenging because of the lack of available healthy autologous vascularized tissue, such as pericranium, after previous repair; difficulty with surgical dissection due to scar tissue; and the risk of wound healing complications.
The first report of a successful endoscopic repair of a CSF leak was by Wigand in 1981 . Hirsch described the first 2 successful endonasal repairs of sphenoid sinus CSF leaks by using a rotational nasoseptal mucosal flap in 1952 . Currently, endoscopic repair of large skull base defects using a vascularized pedicled nasoseptal flap (PNSF), also referred as the Hadad-Bassagasteguy flap, has gained popularity because of its success in lowering postoperative CSF leak rates after endoscopic skull base surgery . Given the promising results of the PNSF, we have adopted this technique as a salvage method for persistent or delayed CSF rhinorrhea after failed repair from open skull base surgery. In this report, we describe 4 cases of persistent CSF rhinorrhea after open skull base operations that were successfully treated endoscopically with a vascularized PNSF. This strategy offers a minimally invasive solution without incurring the risks associated with revision craniotomy. To our knowledge, using the PNSF in this setting has not been previously reported in the literature.
2
Materials and methods
Between February 2009 and February 2012, 96 skull base dural defects were repaired using a vascularized PNSF by the senior authors (JAE and JKL). All cases were retrospectively reviewed to identify patients who presented with persistent or delayed CSF rhinorrhea after an open skull base approach, and were subsequently treated endoscopically with a vascularized PNSF. Four cases that met these criteria were identified and discussed in this report. Their details are summarized in Table 1 . The history, physical examination, pathology, initial open skull base approach, use of lumbar drain, and repair technique were reviewed. The protocol for this study was reviewed and approved by the institutional review board of The University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ.
| Patient no. | Age | Sex | Pathology | Closure | FU (months) |
|---|---|---|---|---|---|
| 1 | 77 | F | SCC | Autologous fat, AD, NSF, Tisseel | 31 |
| 2 | 28 | F | Meningioma | AD, NSF | 15 |
| 3 | 24 | F | Traumatic GSW | AD, NSF | 9 |
| 4 | 45 | M | Traumatic GSW | FL, NSF | 31 |
2
Materials and methods
Between February 2009 and February 2012, 96 skull base dural defects were repaired using a vascularized PNSF by the senior authors (JAE and JKL). All cases were retrospectively reviewed to identify patients who presented with persistent or delayed CSF rhinorrhea after an open skull base approach, and were subsequently treated endoscopically with a vascularized PNSF. Four cases that met these criteria were identified and discussed in this report. Their details are summarized in Table 1 . The history, physical examination, pathology, initial open skull base approach, use of lumbar drain, and repair technique were reviewed. The protocol for this study was reviewed and approved by the institutional review board of The University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ.
| Patient no. | Age | Sex | Pathology | Closure | FU (months) |
|---|---|---|---|---|---|
| 1 | 77 | F | SCC | Autologous fat, AD, NSF, Tisseel | 31 |
| 2 | 28 | F | Meningioma | AD, NSF | 15 |
| 3 | 24 | F | Traumatic GSW | AD, NSF | 9 |
| 4 | 45 | M | Traumatic GSW | FL, NSF | 31 |
3
Results and summary of cases
Four patients (3 women, 1 man) who underwent salvage endoscopic PNSF repair of persistent or delayed CSF rhinorrhea after an open skull base operation were identified. The mean age was 43.5 (range, 24–77). All patients had successful PNSF repair of their skull base defect without further CSF leakage after a mean follow-up of 21.5 months (range, 9–31). All patients were followed postoperatively with nasal endoscopy on an outpatient basis. There were no complications of infection, flap necrosis or contraction, mucocele, epistaxis, or recurrent CSF leakage.
3.1
Case 1
A 77-year-old woman underwent an anterior craniofacial resection of a left sinonasal squamous cell carcinoma. The skull base dural defect was repaired primarily using a dural allograft supplemented by a vascularized pericranial flap. Three weeks later, she presented with delayed CSF rhinorrhea and significant pneumocephalus that was refractory to conservative management. A lumbar drain was placed with intrathecal injection of fluorescein for intraoperative localization of the CSF fistula. A large anterior skull base defect, approximately 3 × 2 cm, was noted just posterior to the anterior table of the frontal sinus. The defect was repaired in a multilayered fashion using autologous fat graft, acellular dermal allograft (LifeCell Corp, Branchburg, NJ), followed by a vascularized PNSF and Tisseel fibrin glue (Baxter Healthcare Corp, Deerfield, IL). Her postoperative course was unremarkable. She received postoperative chemoradiation and no recurrence of CSF rhinorrhea was noted after 31 months.
3.2
Case 2
A 28-year-old woman underwent a right-sided total petrosectomy for resection of a recurrent petrosal skull base meningioma that was previously treated with stereotactic radiosurgery. During the petrosectomy, entrance into the lateral recess of the sphenoid sinus was noted, and subsequent multilayer repair of the defect was performed with autologous fat and fascia lata graft. The dura was repaired with dural allograft and acellular dermal allograft. Because this was a revision surgery for tumor recurrence, there was no available pericranium for repair. Two weeks later, she developed delayed CSF rhinorrhea. A lumboperitoneal shunt was placed which stopped the leak. Three weeks later, she presented with worsening headaches due to pneumocephalus. Computed tomographic (CT) scan of the paranasal sinuses demonstrated a 1-cm bony defect of the right inferolateral wall of the sphenoid sinus ( Fig. 1 A-B ). The pneumocephalus was felt to be entering through the sphenoid sinus defect and also possibly through the Eustachian tube. The patient underwent salvage endoscopic PNSF repair of the sphenoid sinus defect with endoscopic obliteration of the right Eustachian tube with acellular dermal allograft ( Fig. 1 C-E). Postoperatively, the patient’s headaches resolved and there was no further CSF leakage. There was complete resolution of pneumocephalus noted on a 3 month follow-up magnetic resonance imaging scan ( Fig. 1 F), and no recurrence of CSF leak at 15-month follow-up examination.
