Optic nerve sheath diameter correlates to intracranial pressure in spontaneous CSF leak patients.

BACKGROUND: Spontaneous cerebrospinal fluid (sCSF) leaks develop from pressure erosion due to idiopathic intracranial hypertension, treatment of which is paramount to preventing recurrence. Direct measurements of intracranial pressure (ICP) for monitoring response to treatment via lumbar drain (LD) or ventriculostomy are invasive and have risks. The objectives of this study are to determine whether ultrasonographic measurements of optic nerve sheath diameter (ONSD) correlate with LD ICP in patients with sCSF leaks undergoing treatment, and whether ONSDs are larger in patients with sCSF leaks than controls. METHODS: Subjects with sCSF leaks and controls were prospectively recruited. ONSD, sex, and body mass index (BMI) were analyzed. For sCSF leak subjects, ultrasonography was performed at the time of LD opening and each pressure check postoperatively, including the acetazolamide response. In control patients, measurements were obtained at the time of surgery. Pearson's correlation between ONSD and ICP was performed. RESULTS: Subjects with sCSF leaks (n = 9, age 52.4 ± 9.5, all female) and controls (n = 8, age 60.1 ± 14.8, two females) had significantly different BMIs, 38.4 ± 8.1 vs. 29.2 ± 4.8, t(15) = 2.793, p = 0.014. ONSD was strongly correlated with ICP measurements (r = 0.583, p = 0.002). However, percentage change in ONSD and ICP measurements were more strongly correlated (r = 0.733, p < 0.001). Patients with sCSF leaks had significantly higher ONSDs than controls, 0.63 cm ± 0.044 vs. 0.56 cm ± 0.074, t(15) = 2.329, p = 0.034. CONCLUSION: ONSD significantly correlated with ICP in sCSF leak patients and was wider in sCSF leak subjects than controls. Ultrasonography has utility in monitoring the ICP response to acetazolamide.

Treatment of Frontal Sinus Osteomyelitis in the Age of Endoscopy.

OBJECTIVE: Frontal sinus osteomyelitis is a severe complication which can result from chronic rhinosinusitis, trauma, or as a complication of reconstruction or obliteration of the frontal sinus. The objective of the current study is to evaluate the contemporary management of frontal sinus osteomyelitis in light of recent advancements in endoscopic surgical techniques. METHODS: Review of a prospectively collected database of patients with frontal sinus pathology was performed from 2008-2020. Data from individuals with frontal sinus osteomyelitis was collected including demographics, etiology, surgical technique, adjunctive medical treatments, complications, and clinical follow up. RESULTS: Sixteen patients (average age 48.3, range 8-84) were included in the study. An open approach was utilized in 6 patients (2 osteoplastic flaps, 3 Reidel procedures, 1 cranialization). Seven patients underwent completely endoscopic approaches (3 Draf IIB, 4 Draf III), while 3 individuals had combined procedures (Lynch with Draf III, osteoplastic flap + Draf III, fistula excision + Draf IIb). All patients received 6 weeks of antibiotics. Average clinical follow up was 24.4 months with no patients requiring revision procedures. CONCLUSION: Endoscopic, endoscopic-assisted, and open approaches were utilized successfully in the current series of patients with osteomyelitis of the anterior table of the frontal sinus. While the progression of endoscopic techniques allows an additional surgical treatment option, it is important to select patients appropriately as open procedures continue to have an important role in the treatment algorithm.

Efficacy of corticosteroid solution administration via Mygind's position for the management of chronic rhinosinusitis with nasal polyps.

OBJECTIVE: To investigate whether direct steroid application via Mygind's position improved objective and subjective measures of chronic rhinosinusitis with nasal polyposis (CRSwNP). METHODS: A retrospective chart review was performed on patients seen by the senior author in a Rhinology Clinic of a tertiary academic center over a 2 year period. Patients whose only change in medical regimen was initiation of corticosteroid administration via Mygind's position were included for this analysis. The main subjective and objective outcome measures were Sino-nasal Outcome Test-22 (SNOT-22) and endoscopy scores, respectively. Patient scores before and after the change in treatment were compared and analyzed using Student's t test and Wilcoxon signed-rank test. RESULTS: Twenty-two patients were identified for inclusion. There was a statistically significant decrease in overall nasal endoscopy scores for both the right (P = .001) and left (P = .001) sides. A statistically significant and clinically meaningful decrease in total SNOT-22 scores (12.7 points, P = .008) was also seen. Intolerance to the regimen was observed in 5/48 patients reviewed for inclusion (10.4%), with issues including neck pain, burning, pressure, and thrush. CONCLUSION: The direct application of topical corticosteroids, specifically via Mygind's position, may improve both objective exam findings and clinical symptomatology in patients with CRSwNP compared to indirect application. Intolerance to the regimen can be observed. LEVEL OF EVIDENCE: 4-Case series (with or without comparison).

Preoperative management of spontaneous cerebrospinal fluid rhinorrhea with acetazolamide.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) rhinorrhea has been associated with elevated intracranial pressure (ICP). As such, ICP reducing measures are commonly employed to optimize repair. Although postoperative acetazolamide use has been described, no data currently exists on the potential for preoperative use. METHODS: A retrospective review was performed including patients treated for anterior spontaneous CSF leaks by a single surgeon over a 6-year period during which acetazolamide therapy (250 mg twice daily) was employed before considering surgical repair. The primary endpoint was whether the patient went on to require surgical repair. RESULTS: A total of 16 patients were identified who were pretreated with acetazolamide. Leak sites were noted as cribriform (5/16), sphenoid (8/16), ethmoid (1/16), multiple (1/16), and indeterminate (1/16). Five patients had resolution of their rhinorrhea without surgery (31.3%). Mean follow-up for these nonsurgical patients was 470 days (range, 64 to 857 days). There were no differences in the patients' age or site of leak between surgical and nonsurgical patients (p = 0.65, p = 0.52, respectively). Nonsurgical patients had a lower body mass index (BMI) than surgical patients (p = 0.04). CONCLUSION: This is the first study to report the use of acetazolamide therapy as a primary treatment option for spontaneous CSF rhinorrhea. This therapy enabled surgery to be avoided in 31.3% of patients. This would indicate that in the absence of other contraindications for delaying repair, a trial of acetazolamide therapy could be considered as an initial option in the management of isolated spontaneous CSF rhinorrhea.