A Primary Clival Defect: Endoscopic Binostril Approach With Nasal Septal Flap Closure and Preservation of Septal Integrity.

Primary spontaneous cerebrospinal fluid (CSF) rhinorrhea is an unusual phenomenon that may occur anywhere along the skull base. However, CSF leaks originating from clival defects are rarely reported in the literature. The majority of reported cases were managed with microscopic techniques, using free grafts. The present study discusses a case of spontaneous CSF rhinorrhea from a clival defect closed with our transnasal operative approach using endoscopic techniques. The skull base defect was successfully managed with an endoscopic binostril approach to create a nasal septal flap pedicled at the sphenopalatine artery, while also preserving the integrity of the nasal septum.

Chemical and cytological analysis of cerebral spinal fluid after intrathecal injection of hypodense fluorescein / Análise química e citológica do líquor após injeção intratecal de solução hipodensa de fluoresceína

ABSTRACT INTRODUCTION: Intrathecal fluorescein has been effective for topographic diagnosis of rhinoliquorrhea. Nonetheless, there are no reports on the study of cerebral spinal fluid (CSF) after use of intrathecal fluorescein. OBJECTIVE: A prospective study attempting to evaluate CSF through chemical and cytological analysis, after injection of fluorescein. METHODS: Prospective analysis of 24 samples of CSF after intrathecal injection of fluorescein for topographic diagnosis of CSF fistulae, collected at the time of puncture and after 24 and 48 h, divided by cellularity: Group 1, up to five cells, and Group 2, with more than five cells. RESULTS: The yellow-greenish color of CSF remained after 48 h in 36%, evidencing permanence of fluorescein. No changes in protein and glucose levels were observed between 0-24 h and 0-48 h. In group 2, an increase in cell count was observed between 24 h and 48 h (p = 0.019). In both groups, there was an increase of neutrophils between 0 and 48 h (p = 0.048) and a decrease between 24 and 48 h (p = 0.05). CONCLUSION: Intrathecal fluorescein provoked discreet meningeal reactions, such as an increase of cells between 24 and 48 h and an increase of neutrophils at 24 h, with a subsequent decrease at 48 h with no correlation with symptomatology.

RESUMO Introdução: A fluoresceína intratecal tem sido efetiva no diagnóstico topográfico da rinoliquorréia. Entretanto, não há estudos no líquor após o uso de fluoresceína intratecal. Objetivo: Estudo prospectivo visando avaliar o líquor, através de análise química e citológica, após injeção de fluoresceína. Método: Análise prospectiva de 24 punções após injeção intratecal de fluoresceína para diagnóstico topográfico de fístula liquórica, coletado no momento da punção, 24 e 48 horas, divididos pela celularidade: grupo 1, com até 5 células e grupo 2 com mais de 5 células. Resultado: A coloração amarelo-esverdeada do líquor permaneceu após 48 horas em 36%, evidenciando permanência de fluoresceína. Observou-se ausência de mudanças no nível de proteína e glicose entre 0-24 horas e 0-48 horas. No grupo 2, um aumento na contagem celular foi observado entre 24 e 48 horas (p = 0,019). No dois grupos juntos, observou-se um aumento de neutrófilos entre 0 e 48 horas (p = 0,048) e uma diminuição entre 24 e 28 horas (p = 0,05). Conclusão: Fluoresceína intratecal provocou discretas reações meníngeas, como o aumento de células entre 24 e 48 horas e aumento dos dos neutrófilos em 24 horas com uma subsequente dimi nuição em 48 horas sem correlação com sintomas.

Chemical and cytological analysis of cerebral spinal fluid after intrathecal injection of hypodense fluorescein.

INTRODUCTION: Intrathecal fluorescein has been effective for topographic diagnosis of rhinoliquorrhea. Nonetheless, there are no reports on the study of cerebral spinal fluid (CSF) after use of intrathecal fluorescein. OBJECTIVE: A prospective study attempting to evaluate CSF through chemical and cytological analysis, after injection of fluorescein. METHODS: Prospective analysis of 24 samples of CSF after intrathecal injection of fluorescein for topographic diagnosis of CSF fistulae, collected at the time of puncture and after 24 and 48h, divided by cellularity: Group 1, up to five cells, and Group 2, with more than five cells. RESULTS: The yellow-greenish color of CSF remained after 48h in 36%, evidencing permanence of fluorescein. No changes in protein and glucose levels were observed between 0-24h and 0-48h. In group 2, an increase in cell count was observed between 24h and 48h (p=0.019). In both groups, there was an increase of neutrophils between 0 and 48h (p=0.048) and a decrease between 24 and 48h (p=0.05). CONCLUSION: Intrathecal fluorescein provoked discreet meningeal reactions, such as an increase of cells between 24 and 48h and an increase of neutrophils at 24h, with a subsequent decrease at 48h with no correlation with symptomatology.

Manejo conservador no tratamento de fístula liquórica nasal iatrogênica / Conservative treatment of iatrogenic nasal CSF fistula

A fístula liquórica nasal, identificada pela presença de líquido cefalorraquidiano na cavidade nasal, é uma condição de risco para o desenvolvimento de meningite. Tal entidade, quando de etiologia iatrogênica, é de incidência significativa naqueles pacientes submetidos a cirurgias endoscópicas nasais e cirurgias da base do crânio. O otorrinolaringologista tem exercido o crucial papel de realizar o diagnóstico e prover o tratamento dessa entidade, com o objetivo de evitar as complicações da infecção meníngea e suas sequelas. No presente estudo descrevemos o caso de um paciente submetido à cirurgia nasal que apresentou rinoliquorreia no período pós-operatório de cirurgia nasal não especificada. O paciente apresentou evolução favorável com manejo conservador. É de suma importância o conhecimento das particularidades diagnósticas e terapêuticas dessa condição devido à sua incidência significativa e às suas complicações potencialmente deletérias (AU)

Nasal CSF leak, identified by the presence of cerebrospinal fluid in the nasal cavity, is a risk factor for the development of meningitis. Such an entity, if iatrogenic, is significantly incident in patients undergoing nasal endoscopic surgery and skull base surgery. The otolaryngologist has played a crucial role in making a diagnosis and provide treatment for such entity, in order to avoid the complications of meningeal infection and its sequelae. In the present study we report the case of a patient undergoing nasal surgery who had CSF leak in the postoperative period of unspecified nasal surgery. The patient presented favorable evolution with conservative management of the condition, with evidence of fistula closure through control cisternotomography. Knowledge of the diagnostic and therapeutic characteristics of this condition is very important due to its significant incidence and its potentially harmful complications (AU)

Anterior skull base cerebrospinal fluid fistulas in Puerto Rico: treatment and outcome.

BACKGROUND: The surgical management of anterior skull base cerebrospinal fluid (CSF) fistulas has evolved throughout the last decade. Endonasal endoscopic surgery of the anterior skull base has become the standard procedure for the repair of most these fistulas. OBJECTIVES: To describe the presenting symptoms, etiology, treatment, and long-term outcomes of patients with anterior skull base CSF fistulas treated endoscopically at our institution. MATERIAL/ METHODS: Retrospective analysis of 25 patients with CSF fistulas treated endoscopically at the University of Puerto Rico Hospital from November 2004 to August 2008. RESULT: The etiology was spontaneous leak in 10 patients, menigoencephalocele in 7 patients, previous sinus surgery in one patient, and trauma in one patient. The most common location of leak was the cribiform plate, followed by the ethmoid roof. An overlay technique was used for repair in 61% of the procedures versus 39% for the underlay technique. The mean follow up was 23 months. Our overall initial rate of closure was 94% with 100% after a second procedure. CONCLUSIONS: Endoscopic repair of anterior skull base CSF fistulas has a high success rate and lower morbidity and mortality when compared with open approaches.

Predictability of quantification of beta-trace protein for diagnosis of cerebrospinal fluid leak: cutoff determination in nasal fluids with two control groups.

BACKGROUND: Cerebrospinal fluid (CSF) leak of the anterior skull base is an abnormal communication between the subarachnoid space and the nasal cavity or the paranasal sinus. Its presence increases the incidence of complications, as meningitis, with risk of sequelae. The early and correct diagnosis of the CSF leaks is important to perform surgical treatment as soon as possible. The CSF detection in nasal fluids could be made through the beta2-transferrin (beta2Tr) immunoelectrophoretic test, an expensive and cumbersome immunologic test, not available to the majority of the Brazilian hospitals. Recently, the detection of beta-trace protein (betaTP) for identification of CSF leaks has been described. The literature suggests there may be similar sensitivity and specificity to tests of beta2Tr, because betaTP is also a specific brain protein and it is present in CSF in high concentrations. The majority of Brazilian hospitals have the nephelometric equipment for betaTP detection. This study was designed to determine threshold values for betaTP concentrations in nasal cavity secretions as a predictor of CFS leak. METHODS: Nasal secretions were collected from patients with suspicion of CSF leak and from healthy volunteers. Pure CSF samples were used. A nephelometric assay was used to determine the betaTP concentration in samples. RESULTS: Values between 0.244 and 0.496 mg/L were determined for the cutoff. CONCLUSION: Beta-trace concentrations above 0.496 mg/L are highly suggestive of the presence of CSF in examined nasal secretion. Positive predictive value and negative predictive value were 100%. BetaTP nephelometric test can predict the side of the CSF leak.

Current imaging of cerebrospinal fluid leaks / Imágenes médicas actuales de pérdidas de fluido cerebroespinal

A CSF leak results from a defect in the dura and skull base. Due to the risk of potentially devastating central nervous system infection, it is an important entity. Timely diagnosis of CSF leaks is crucial. Laboratory testing of nasal or aural fluid drainage for the presence of the protein Beta(β)-2 transferrin plays a key role in establishing the presence of a CSF leak. Such assays are not always available, making imaging pivotal in the diagnosis of this entity. The development of minimally invasive endoscopic repair further underscores the importance of imaging as precise anatomic localization is important for repair. In this article, we review the literature and make suggestions for the appropriate radiological investigation ofpatients with suspected CSF leaks.

Las pérdidas de fluido cerebroespinal (FCE) son el resultado de un defecto en la dura y la base craneal. Debido a que tales pérdidas presentan el riesgo de infecciones capaces de devastar potencialmente el sistema nervioso central, las mismas constituyen una entidad importante. El diagnóstico a tiempo de pérdidas del FCE es crucial. Las pruebas de laboratorio realizadas al drenaje del fluido de la nariz y los oídos a fin de detectar la proteína Beta (β) 2 transferrina, desempeñan un papel clave a la hora de determinar la presencia de pérdida de FCE. Estos ensayos no se hallan siempre a disposición, con lo cual la imagen médica se hace fundamental para el diagnóstico de esta entidad. El desarrollo de reparaciones endoscópicas mínimamente invasivas subraya aún más la importancia de la imagen médica, por cuanto se requiere una localización anatómica precisa para realizar la reparación. En el presente artículo, se revisa la literatura y se hacen sugerencias a fin de lograr una investigación radiológica adecuada de los pacientes con sospecha de pérdida de FCE.

Current imaging of cerebrospinal fluid leaks.

A CSF leak results from a defect in the dura and skull base. Due to the risk of potentially devastating central nervous system infection, it is an important entity. Timely diagnosis of CSF leaks is crucial. Laboratory testing of nasal or aural fluid drainage for the presence of the protein Beta (beta)-2 transferrin plays a key role in establishing the presence of a CSF leak. Such assays are not always available, making imaging pivotal in the diagnosis of this entity. The development of minimally invasive endoscopic repair further underscores the importance of imaging as precise anatomic localization is important for repair In this article, we review the literature and make suggestions for the appropriate radiological investigation of patients with suspected CSF leaks.

Manejo endoscopico de las fístulas de líquido céfalo raquídeo del piso craneal anterior / Endoscopic treatment of cerebrospinal fluid fistulae of skull base

La fístula de líquido céfalo raquídeo (LCR) implica un quiebre de todas las barreras entre el espacio subaracnoideo y el tracto aéreo digestivo superior. Es una condición seria y fatal. La meningitis bacteriana es la mayor causa de morbilidad y mortalidad asociada a esta condición. Existen múltiples clasificaciones que tratan de sistematizar este problema, algunas de ellas son de escaso valor para el clínico. Existe una evolución en los métodos diagnósticos y terapéuticos en esta patología. Se presenta el marco teórico de la patología, evolución de la técnica quirúrgica, conceptos actuales en la reparación endoscópica de las fístulas de LCR y la experiencia quirúrgica desarrollada por los autores en 24 pacientes tratados en el Hospital Regional de Concepción durante el periodo abril 2001 a agosto 2008.

Cerebrospinal Fluid (CSF) fistulae involves a breakdown of all barriers that separates de subarachnoid space from the upper aero digestive tract. It is a serious and sometimes fatal condition. Meningitis is the mayor cause of morbidity anc mortality. There are many classifications trying to deal witt this issue, some of them with mean less clinical value. There is an evolution in diagnostic and therapeutic methods in this pathology We present the theoretical frame of this pathology, the evolution of the surgical technique, the current concepts in the endoscopic repair of CSF fistulae and the surgical experience developed by the authors in 24 patients treateo at the Hospital regional de Concepcion between April 2001 and August 2008.

Cerebrospinal fluid rhinorrhoea: diagnosis and management.

A cerebrospinal fluid (CSF) rhinorrhoea occurs when there is a fistula between the dura and the skull base and discharge of CSF from the nose. CSF rhinorrhea or liquorrhoea commonly occurs following head trauma (fronto-basal skull fractures), as a result of intracranial surgery, or destruction lesions. A spinal fluid leak from the intracranial space to the nasal respiratory tract is potentially very serious because of the risk of an ascending infection which could produce fulminant meningitis. This article reviewed the causes, diagnosis and treatment of CSF leakage. A PUBMED search of the National Library of Medicine was conducted. CSF leak most commonly occurs following trauma and the majority of cases presenting within the first three months. CSF rhinorrhoea have significantly greater incidence of periorbital haematoma. This suggests that patients with head injuries and features of periorbital haematoma are at greater risk of unobserved dural tear and delayed CSF leakage. In the presence of a skull base fracture on computed tomography and a clinical CSF leak, there is no need for a further confirmatory test. In cases where a confirmatory test is needed, the beta-2 transferrin assay is the test of choice because of its high sensitivity and specificity. A greater proportion of the CSF leaks in the patients resolved spontaneously. CSF fistulae persisting for > 7 days had a significantly increased risk of developing meningitis. Treatment decisions should be dictated by the severity of neurological decline during the emergency period and the presence/absence of associated intracranial lesions. The timing for surgery and CSF drainage procedures must be decided with great care and with a clear strategy.

Intrathecal administration of gadopentetate dimeglumine for MR cisternography of nasoethmoidal CSF fistula.

OBJECTIVE: Accurate diagnosis and localization of dural defects associated with CSF fistulas are difficult and often involve multiple imaging studies performed at the appropriate clinical moment. Our purpose was to assess the utility of intrathecal administration of gadopentetate dimeglumine for MR cisternography of patients with CSF fistula suspected clinically to arise from defects in the nasoethmoidal regions. CONCLUSION: MR cisternography was useful for evaluating patients with rhinorrhea and suspected CSF fistula. It depicted the fistula site in most patients. No adverse effects were found in any patient.

Rinorrea traumática de líquido cefalorraquídeo: nuestra experiencia en su diagnóstico y tratamiento / Traumatic cerebrospinal fluid rhinorrhea: our experience in diagnosing and treating this illness

Se realizó un estudio observacional descriptivo longitudinal en el Hospital Clinicoquirúrgico Provincial Docente Manuel Ascunce Domenech de Camagüey, en el período de enero a diciembre del 2004, para evaluar el manejo diagnóstico y terapéutico de la rinorrea traumática de líquido cefalorraquídeo (LCR). Se seleccionaron previo consentimiento informado 16 pacientes provenientes del Servicio de Urgencias. De estos, 11 fueron hombres y el 32 por ciento se encontraba en las edades comprendidas entre 15 y 29 años. Se determinaron síntomas asociados, estudios complementarios, tratamiento médico-quirúrgico, complicaciones y evolución. Se realizó estadística descriptiva e inferencial. Los síntomas más frecuentes fueron las cefaleas (87,5 por ciento), anosmia y vértigos. Los métodos diagnósticos más efectivos fueron la inspección visual (100,0 por ciento), la TAC simple y la rinoscopia. Los tratamientos más frecuentes fueron la antibioticoterapia y reducción de fracturas Lefort y nasoetmoidales con 62,5 por ciento y 87,5 por ciento, respectivamente. El 81,3 por ciento de los casos evolucionó favorablemente, solo 2 (12,5 por ciento) se complicaron con meningitis(AU)

A longitudinal, descriptive and observational study was undertaken from January to December, 2004 at Manuel Ascunce Domenech clinical and surgical hospital in Camaguey province, for the purpose of evaluating the diagnostic and therapeutic management of traumatic cerebrospinal fluid rhinorrhea. After obtaining their informed consent, 16 patients from the Emergency Dental Service were selected. Eleven of them were males and 32 percent was in the 15-29 years old group. Associated symptoms, supplementary studies, medical & surgical treatment, complications and recovery period were considered. Descriptive and inference statistics were used. The most frequent symptoms were headaches (87,5 percent), anosmia and dizziness. The most effective diagnosing methods were visual survey (100 percent), simple CT and rhinoscopy. The most common treatment regimes were antibiotic therapy and LeFort and nasoethmoidal fracture reduction with 62,5 percent and 87,5 percent of cases respectively. Recovery was satisfactory in 81,3 percent of cases, although two (12,5 percent) suffered complications from meningitis(AU)

Endoscopic endonasal approach for cerebrospinal fluid fistulae.

Different techniques have been proposed to repair cerebrospinal fluid rhinorrhea. Advances in nasal surgery led to a high success rate and low morbidity for the endonasal approach. It has become the favorite route for treating cerebrospinal fluid leaks of the anterior skull base. Better results have been obtained with the improvement of rigid endoscopes and intrathecal sodium fluorescein. In a prospective study, twenty-four patients with cerebrospinal fluid rhinorrhea were evaluated and treated by endoscopic endonasal surgery. In all cases intrathecal sodium fluorescein enabled a precise localization of the bone defect. The most common causes of CSF rhinorrhea were traumatic (8 cases, 33 %), spontaneous (6 cases, 25 %), and iatrogenic (5 cases, 20.8 %). Preoperative radiological evaluations (plane CT, CT cisternogram and MRI) showed the exact site and size of the defect in all patients. The most common site of leakage was the ethmoidal roof-cribriform plate. Primary closure was achieved in all patients. There were no major operative or postoperative complications. The endoscopic endonasal approach can be considered the first choice in the treatment of cerebrospinal fluid rhinorrhea.

Correção endoscópica de fístula liquórica rinogênica: experiência de 44 casos / Endoscopic repair of CSF rhinorrhea: experience of 44 cases

A comunicação entre o espaço subaracnóideo e a cavidade nasal ou seios frontal, etmoidal e esfenoidal denomina-se fístula liquórica rinogênica. A fístula liquórica rinogênica tem potencial de complicação com importante morbidade e mortalidade. Ela pode apresentar um verdadeiro desafio no diagnóstico, na sua localização e no seu tratamento. FORMA DE ESTUDO: estudo de série. MATERIAL E MÉTODO: Entre 1993 a 2004, 44 pacientes com fístula liquórica rinogênica foram submetidos à abordagem endoscópica no Hospital das Clínicas da Universidade de São Paulo. Os prontuários de todos os pacientes tratados foram revisados. RESULTADO: Quarenta e quatro pacientes, 16 mulheres (36 por cento) e 28 homens (64 por cento) foram incluídos no estudo. A idade variou de 02 a 68 anos (média =40,3). A etiologia, o sítio da fístula, o diagnóstico, a técnica empregada e o seguimento pós-operatório foram discutidos. CONCLUSÃO: Os autores concluíram que a técnica cirúrgica endoscópica endonasal para o tratamento de fístula liquórica rinogênica apresenta elevado sucesso, baixa morbidade e resultados em longo prazo confiáveis.

Endoscopic repair of CSF rhinorrhea: experience of 44 cases.

UNLABELLED: Cerebrospinal fluid (CSF) rhinorrhea is a leakage of fluid from the subarachnoid space to the frontal, sphenoidal or ethmoidal sinuses. CSF rhinorrhea is a known potential complication with significant morbidity and mortality. It may present a significant challenge in diagnosis, localization and management. STUDY DESIGN: Series study. MATERIAL AND METHOD: Between 1993 and 2004, 44 patients with cerebrospinal rhinorrhea were operated on using intranasal endoscopic approach in the University Hospital of the University of Sao Paulo, Medical School. The charts of all patients treated in our hospital were reviewed. RESULTS: Forty-four patients, 16 women (36%) and twenty-eight men (64%), were included in the study. Patients' ages ranged from 2 to 68 years (mean: 40.3 years). Etiology, site of leakage, diagnosis, technique, cause of failure and follow-up are discussed. CONCLUSION: The authors concluded that transnasal endoscopic surgery for CSF rhinorrhea had high success rate, low morbidity and stable long-term results.

A new technique for the use of intrathecal fluorescein in the repair of cerebrospinal fluid rhinorrhea using a hypodense diluent.

The intrathecal injection of fluorescein is used in the diagnosis and treatment of skull base liquoric fistulas since it allows precise localization of the site of drainage. The fluorescein is always diluted in cerebrospinal fluid (CSF) resulting in a hyperdense solution in relation to the CSF. For this reason it is necessary to put the patient in the Trendelenburg position for 30 to 40 minutes so that the fluorescein reaches the cerebral cisterns and is visualized at the level of the fistulae. From October 1997 to May 1999 intrathecal fluorescein in a hypodense solution was used in the repair of 23 skull base defects associated with CSF rhinorrhea. This hypodense solution was obtained by diluting 0.5 cm3 of 5% fluorescein in 10 cm3 of distilled water. This solution density is 1001, which is hypodense when compared to CSF (density range 1004-1006) and therefore allows fluorescein to reach rapidly the cerebral cisterns when the patient is recumbent. The author discusses the advantages and the lack of complications with the use of fluorescein in a hypodense solution.

Fístulas crânio-nasais do líquido céfalo-raquiano. Estudo de 17 casos / Cerebrospinal fluid cranio-nasal fistulae. Report of 17 cases

Os autores estudam uma série de pacientes com fístula do líquido céfalo-raquiano (LCR). Analisam as etiologias mais comuns desse tipo de fístula e as classificam didaticamente em dois grandes grupos: espontâneas e traumáticas. O objetivo deste estudo é discutir a conduta terapêutica e chamar a atenção para as principais dificuldades no diagnóstico dessas lesões.

Fístula liquórica como diagnóstico diferencial de rinite / Cerebrospinal fluid fistula as differential diagnosis from rhinitis

A rinite alérgica representa uma das doenças mais freqüentes na prática diária do alergologista, otorrinolaringologista e do clínico, caracterizando-se clinicamente por espirros mültiplos, coriza hialina, prurido e obstruçäo nasais. A fístula liquórica, mesmo sendo pouco freqüente, é diagnóstico diferencial importante das rinites. Nesta revisäo procuramos abordar, de forma sucinta, características clínicas, fisiopatologia, diagnóstico laboratorial e tratamento da entidade.