The benefit of early lumbar drain insertion in reducing the length of CSF leak in traumatic rhinorrhea.

OBJECTIVE: In traumatic CSF leaks, the early lumbar drain (LD) placement could significantly shorten the rhinorrhea period. METHODS: Included were patients presenting CSF rhinorrhea subsequent to closed head trauma, admitted within 24h. Patients were randomly allocated into two treatment arms: 30 patients within Group A with CSF diversion via LD and 30 patients in Group B managed conservatively with bed rest and head elevation. Primary outcome was length of CSF rhinorrhea. Secondary outcomes were recurrent CSF leaks and meningitis occurrence. RESULTS: In Group A leak stopped within 10 days, in Group B leak persisted beyond 10 days in 2 patients. In Group A CSF leak time was 4.83±1.88 days while in Group B was 7.03±2.02 days. The difference is statistically significant: 2.2 days (95% CI 3.05-1.35), p<0.0001. During follow-up recurrent CSF leak developed in 7 patients (23%) in Group A and in 8 patients (27%) in Group B (p=0.63, not significant). Meningitis occurred in 3 patients in Group A (10%) and in 4 cases in Group B (13%) (p=0.61, not significant). CONCLUSIONS: The initial use of LDs in highly selected patients with traumatic CSF rhinorrhea resulted in a significant decrease of leakage. Nevertheless, the benefits should be carefully weighted with drawbacks.

Effectiveness of lumbar drains on recurrence rates in endoscopic surgery of cerebrospinal fluid leaks.

BACKGROUND: In cerebrospinal fluid (CSF) leakage endoscopic repair, lumbar drains (LDs) were used in an attempt to increase success rates. To critically assess the relationship between use of LDs and recurrent leaks, we embarked on this randomized prospective study. METHODS: Patients undergoing CSF leak repair between 2000 and 2012 were randomized into two groups: 75 patients were managed without LDs and in the other group of 75 patients an LD was always placed. Different parameters were analyzed to identify their relationship with failures: occurrence of increased intracranial pressure (ICP), body mass index, smoking habits, existence of diabetes, chronic corticosteroid use, previous sinus surgery, etiology (traumatic, iatrogenic, or spontaneous leak), site, and size of the CSF leak. RESULTS: Success rate was 93% for the whole group. Patients managed with LDs attained 95% success rate and those without LD attained 92%; the difference is not significant (p = 0.2). The only factor predictive of recurrence is increased ICP: 77% success rate versus 97% for traumatic leaks and 96% for iatrogenic leaks. Recurrence rates were identical in the two groups with increased ICP, regardless of the use of a LD (23%). CONCLUSION: In this study, success rates of CSF repair were not associated with the use of LDs. However, the small number of cases with high success rates precludes appropriate statistical analysis.

Bacteriology of normal frontal sinuses.

PURPOSE: The aim of this cross-sectional trial was to identify the bacterial flora and to quantify the level of bacterial presence in healthy adult frontal sinus cavities. MATERIALS AND METHODS: Ninety five consecutive patients undergoing craniotomy of the anterior cranial fossa were enrolled. All patients were evaluated preoperatively by a sino-nasal questionnaire, nasal endoscopy and CT scan. Exclusion criteria were patients with sinus tumours, presenting a cold in the past 8 weeks, having signs or symptoms suggestive of sinus disease, history suggestive of allergic rhinitis and/or asthma, having undergone hospitalization or an outpatient clinic visit within the past 12 months, patients with known systemic disease, having previous sinus or nose surgery, history of trauma of the sino-nasal region, or having used systemic antibiotics, steroids, or nasal spray in the past 8 weeks. Lavages were obtained from frontal sinuses before craniotomy through trephination of the anterior wall. The sinus was irrigated with sterile saline followed by aspiration. Specimens were inoculated for aerobic and anaerobic organisms. RESULTS: After applying the exclusion criteria, 42 patients (84 sinuses) were finally included in the study. Bacterial organisms were recovered in 12 of 84 (14.28%) sinuses. However, 85.72% of the sinuses were found to be sterile. Bacteria recovered included three different coagulase-negative staphylococci, one Citrobacter diversus and two Micrococcus spp. No anaerobic organism was isolated. CONCLUSIONS: This study demonstrated that the majority of frontal sinuses of asymptomatic adults with normal CT and endoscopic appearance are sterile.