phenylephrine-hydrochloride and Cerebrospinal-Fluid-Rhinorrhea

To assess existing literature on topical intranasal fluorescein (TINF) for the diagnosis and localization of nasal cerebrospinal fluid (CSF).. Systematic review.. A 6-database literature search was conducted to identify articles providing insight into TINF for the diagnosis and treatment of sinonasal CSF leak. Demographic characteristics, technical details, efficacy, and safety data were extracted and analyzed. Methodological quality was assessed using Methodological Items for Non-Randomized Studies (MINORS) criteria.. All studies reported a diagnostic accuracy rate ≥96%. There were no major complications reported for any patient (n=99) with either 5% or 10% fluorescein use. The MINORS instrument of methodological quality indicated that the assessed studies were of moderate quality (7.29 out of a maximum score of 24).. This systematic review indicates that TINF is an easy, safe, inexpensive, and sensitive approach for the diagnosis and treatment of sinonasal CSF leakage. For these reasons, it may be especially well suited for resource-limited clinical scenarios.

Topics: Administration, Intranasal; Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Fluorescein; Humans; Nose; Retrospective Studies

Topics: Cerebrospinal Fluid Rhinorrhea; Endoscopy; Eustachian Tube; Humans; Nose

This article presents an overview of endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea. In recent years, endoscopic repair has become the standard of care for managing this condition, because it gradually replaces the traditional open transcranial approach. Discussion includes the etiologic classification of CSF rhinorrhea, management paradigm for each category, diagnosis algorithm, comprehensive description of the surgical technique, and an updated review of the literature regarding the safety and efficacy of this procedure. In addition, the authors present their experience, including 2 surgical videos demonstrating endoscopic repair of CSF rhinorrhea in 2 distinct clinical scenarios.

Topics: Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Ethmoid Bone; Female; Head Injuries, Closed; Humans; Male; Nasal Septum; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Paranasal Sinuses; Pseudotumor Cerebri; Surgical Flaps; Young Adult

Cerebrospinal fluid (CSF) leaks most commonly arise during or after skull base surgery, although they occasionally present spontaneously. Recent advances in the repair of CSF leaks have enabled endoscopic endonasal surgery to become the preferred option for management of skull base pathology. Small defects (<1 cm) can be repaired by multilayered free grafts. For large defects (>3 cm), pedicled vascular flaps are the repair method of choice, resulting in much lower rates of postoperative CSF leaks. The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for the vast majority of skull base defects. It has a large area of potential coverage and high rates of success. However, preoperative planning is required to avoid sacrificing the NSF during resection. In cases where the NSF is unavailable, often due to tumor involvement of the septum or previous resection removing or compromising the flap, other flaps may be considered. These flaps include intranasal options - inferior turbinate or middle turbinate flaps - as well as regional pedicled flaps: pericranial flap, temporoparietal fascial flap, or palatal flap. More recently, novel alternatives such as the pedicled facial buccinator flap and the pedicled occipital galeopericranial flap have been added to the arsenal of options for skull base reconstruction. Characteristics of and appropriate uses for each flap are described.

Topics: Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Humans; Nose; Plastic Surgery Procedures; Skull Base; Skull Base Neoplasms; Surgical Flaps; Turbinates

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.

Topics: Adenoma; Adolescent; Adult; Cerebrospinal Fluid Rhinorrhea; Diabetes Insipidus; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Sinusitis

The majority of spontaneous cerebrospinal fluid leaks occur at the anterior skull base; few cases at the temporal bone have been described. There have been no previous reports of synchronous leaks at the anterior skull base and temporal bone in the same patient.. Case report and brief review of management of spontaneous cerebrospinal fluid leaks in the nose and ear.. A 34-year-old, pregnant woman presented with watery nasal discharge and unilateral middle-ear effusion. The nasal and ear secretions both proved to be cerebrospinal fluid. Radiological imaging showed defects in both the ethmoid roof and the mastoid roof (middle cranial fossa). These defects were surgically closed using duraplasties.. A literature review indicated that this is the first reported case of synchronous spontaneous cerebrospinal fluid leaks via the anterior skull base and temporal bone.

Topics: Adult; Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Ear; Female; Humans; Nose; Pregnancy; Skull Base; Temporal Bone

Trauma and surgery are the most common causes of cerebrospinal fluid (CSF) rhinorrhea. Surgical repair is recommended for patients with CSF leaks that do not respond to conservative measures, traumatic CSF leaks that require transcranial surgery for associated brain injuries, and iatrogenic defects that are discovered intraoperatively. The purpose of our study was to ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair.. We performed a meta-analysis of all studies published in English between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. We analyzed data that included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics. The success rate was monitored and correlated with the other variables. The meta-analysis database was compared with and added to a database comprising our own patients.. Fourteen studies comprising 289 CSF fistulae met the inclusion criteria. Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication.. The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Retrospective Studies

The anterior skull base can be approached intranasally, and the development of endoscopes and accompanying endoscopic instruments in recent years makes possible extremely precise and defined work along the ethmoid and sphenoid sinus roof. Since these areas are the most frequent locations of anterior skull base CSF rhinorrhea, it follows that the localization and subsequent closure of these defects theoretically can be accomplished in this manner. Our report and others show that closure of CSF leaks can be accomplished successfully using this procedure, with minimal morbidity and at a fraction of the cost of frontal craniotomy. In our opinion, this should become the initial procedure of choice for closure of anterior fossa CSF leaks in amenable cases.

Topics: Adult; Cartilage; Cerebrospinal Fluid Rhinorrhea; Endoscopes; Endoscopy; Ethmoid Sinusitis; Female; Humans; Maxillary Sinusitis; Metrizamide; Nose; Postoperative Complications; Tomography, X-Ray Computed

Topics: Cerebrospinal Fluid Rhinorrhea; Cranial Nerve Injuries; Diplopia; Ethmoid Bone; Ethmoid Sinus; Fixation, Ocular; Fractures, Bone; Hemorrhage; Humans; Lacrimal Apparatus; Maxillofacial Injuries; Nose; Oculomotor Muscles; Oculomotor Nerve Injuries; Orbit; Radiography; Tendon Injuries; Vision Disorders; Visual Acuity

To describe surgical endoscopic experience in the repair of cerebrospinal fluid leaks treated by transnasal approaches.. Different surgical approaches and techniques in the repair of cranial base defects are reviewed in a series of 135 patients.. Success rate at first attempt was 93.3%. Only 9 patients (6.7%) needed a second surgical repair, and in one patient, a coronal approach with frontal craniotomy was necessary. In the other eight cases, an endoscopic procedure was chosen. Two patients needed a third endonasal endoscopic surgical repair, with successful outcome.. The target of endoscopic endonasal technique in the repair of cerebrospinal fluid leaks is to ensure a stable duraplasty with the least invasive approach avoiding craniotomy. A correct diagnosis surely allows the choice of the best treatment, surgical approach, graft, and technique. Our multidisciplinary approach to this pathology during these years has been essential to gain our challenging results.

Topics: Adolescent; Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Decision Trees; Endoscopy; Female; Follow-Up Studies; Humans; Infant; Magnetic Resonance Imaging; Male; Medical Illustration; Middle Aged; Nose; Otorhinolaryngologic Surgical Procedures; Postoperative Care; Prostheses and Implants; Retrospective Studies; Skull Base; Sphenoid Sinus; Tomography, X-Ray Computed; Treatment Outcome

Topics: Cerebrospinal Fluid Rhinorrhea; Ethmoid Sinus; Humans; Nasal Polyps; Nose

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anatomic Landmarks; Central Nervous System Neoplasms; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Epistaxis; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Postoperative Complications; Prospective Studies; Retrospective Studies; Sphenoid Sinus; Young Adult

Cerebrospinal fistulas of the clivus region often result from previous surgical intervention at the skull base. The localization and size of the fistula determine the appropriate treatment strategy. When flap closure is not possible, the microsuture technique with autograft placement provides a favorable outcome.. We present a technical report on the application of the microsuture technique for clivus region cerebrospinal fluid fistula closure in a patient with previous chordoma treatment and nonspecific coronavirus disease 2019 complications.. The application of the microsuture technique resulted in stable remission of the fistula and complete regression of the clinical manifestations.. The microsuture technique for clivus region fistula closure is a potentially valuable alternative to vascularized flap closure.

Topics: Adult; Cerebellar Vermis; Cerebrospinal Fluid Rhinorrhea; Cranial Fossa, Posterior; Female; Humans; Nose; Plastic Surgery Procedures; SARS-CoV-2; Skull Base; Surgical Flaps

The pedicled nasoseptal flap (NSF) constitutes the primary reconstructive option for most skull base defects in endonasal endoscopic approaches. The superior nasal turbinate (ST) has received little attention. We report our preliminary experience with the use of the ST mucosal flap in selected cases.. We performed a retrospective review of patients who underwent endonasal endoscopic approaches and identified 9 patients who were reconstructed with vascularized ST mucosal flaps as part of a double-layer or triple-layer reconstruction. When there was no intraoperative cerebrospinal fluid (CSF) leak, we used a double-layer technique. If there was an intraoperative CSF leak, regardless of the quality of leakage, we preferred a triple-layer repair technique. In patients with high-flow leaks, triple-layer repair was performed using only autologous tissue grafts and flaps.. Intraoperative CSF leaks were noted in 7 of 9 patients. Among them, 4 patients had low-flow CSF leaks (grade 1 and 2) and 3 patients had high-flow CSF leaks (grade 3). All reconstructions had complete defect coverage with the ST flaps and NSFs were preserved. All the flaps were viable at 4 weeks without a CSF leak or complication at the reconstruction site. There was no contraction or partial loss of the flap. After a mean follow-up period of 9 months, none of the patients required a flap revision, developed a mucocele, infection, or other complication.. An ST flap can be used for the vascularized reconstruction of sellar defects if it is bilaterally available. This option should not be overlooked and wasted.

Topics: Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Female; Humans; Male; Middle Aged; Nasal Mucosa; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Plastic Surgery Procedures; Postoperative Complications; Retrospective Studies; Skull Base; Surgical Flaps

Nasal meningoencephalocele (encephalocele or cephalocele) is a rare condition with congenital, traumatic, or spontaneous origins. We investigated the clinicopathological characteristics of nasal encephaloceles to improve pathologists' and clinicians' understanding of this disease.. Sixteen patients with nasal encephaloceles were enrolled in this retrospective study investigating the condition's clinical and morphological features.. Patients' average age was 37.8 (±20.8) years. The ratio of men to women was 2.2:1, patients' mean age was 47.4 (±11.8) years, and 10/16 patients had spontaneous encephaloceles. All patients with traumatic and spontaneous encephaloceles presented with cerebrospinal fluid leak. In 9/16 patients, the skull defect site occurred on the lateral wall of the sphenoid sinus. Both congenital patients experienced nasal obstruction. Histopathology, herniated tissues were brain and/or meningeal tissue, and the brain tissue was almost mature glial tissue.. Nasal meningoencephalocele is a rare condition that can be challenging to diagnose. In patients with recurrent clear nasal discharge or in children with a unilateral nasal mass, a high index of suspicion for encephalocele is essential. In this study, spontaneous cases were most common in adults, and the lateral wall of the sphenoid sinus was the most common location.

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Child, Preschool; Encephalocele; Female; Humans; Infant; Male; Meningocele; Middle Aged; Nose; Retrospective Studies; Sphenoid Sinus

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Encephalocele; Female; Humans; Magnetic Resonance Imaging; Nose; Optic Nerve; Pituitary Gland; Tomography, X-Ray Computed

Despite advances in endoscopic techniques, retrochiasmatic craniopharyngiomas (CPs) are difficult to remove completely, because the low-lying optic chiasm often provides an obstacle to an endoscopic endonasal approach. This study aimed to identify the endoscopic surgical outcomes of the retrochiasmatic CP and resolve the issues related to low-lying optic chiasm.. We reviewed 154 consecutive patients with CP who underwent endonasal endoscopic resection from February 2009 to April 2017 at 2 independent institutions. The topographic relationship of the tumor with the third ventricle, stalk, and optic chiasm and clinical outcomes were investigated.. Retrochiasmatic CPs were found in 142 of 154 patients (92.2%). The median follow-up time was 25 months. Gross total resection and near-total resection were achieved in 113 patients (79.6%) and 21 patients (13.8%), respectively. Postoperative cerebrospinal fluid leaks were found in 16 patients (11.3%). Low-lying and high-lying chiasms were found in 44 patients (31.0%) and 98 patients (69.0%), respectively. Low-lying chiasm did not affect clinical outcomes including the extent of resection. Patients with low-lying chiasm showed a marginal trend for postoperative visual deterioration. The ventricular growth pattern representing the origin of the tumor and previous surgery were significantly associated with the position of the optic chiasm (P = 0.007 and 0.001, respectively).. An endoscopic endonasal approach is an effective surgical approach for retrochiasmatic CP, even in tumors with low-lying chiasm. However, a thorough and careful dissection is necessary to prevent visual deterioration.

Topics: Adolescent; Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Female; Humans; Imaging, Three-Dimensional; Male; Middle Aged; Neuroendoscopy; Nose; Ophthalmology; Optic Chiasm; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Statistics, Nonparametric; Tomography Scanners, X-Ray Computed; Young Adult

Topics: Adult; Aged; Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; China; Cranial Nerve Neoplasms; Endoscopes; Endoscopy; Female; Humans; Male; Middle Aged; Neurilemmoma; Nose; Nose Neoplasms; Pterygopalatine Fossa; Retrospective Studies; Skull Base Neoplasms; Surgical Flaps; Treatment Outcome; Trigeminal Nerve Diseases

Primary watertight dural closure is the preferred method of postcraniotomy dural repair. However, even when ideal technique is implemented, postoperative infection, cerebrospinal fluid (CSF) leaks, pseudomeningoceles, and dural scarring are possible complications. For this reason, materials that augment the dura's ability to create a watertight seal, prevent disease transmission, and inhibit inflammatory response are sought. Dehydrated amniotic membrane (DAM) allograft appears to fulfil these requirements as it has several beneficial properties that aid wound healing, including promotion of epithelialization, scar tissue prevention, and inhibition of bacterial growth. We provide the literature's first description of the use of DAM allograft to supplement dural closures for craniotomies and transsphenoidal surgeries.. We conducted a pilot study, retrospectively reviewing our institution's database of craniotomies and transsphenoidal surgeries that utilized DAM to augment dural closure.. One hundred fifty-five cases, including 102 new craniotomies for supratentorial lesions, one re-do craniotomy for supratentorial recurrent glioma, 18 craniotomies for infratentorial lesions, 1 craniotomy for anterior skull base schwannoma, 32 transphenoidal surgeries, and 1 combined craniotomy and transnasal endoscopic surgery, used DAM allograft to augment dural closure. Only one complication occurred (0.6% complication rate), which was a superficial wound infection requiring washout without craniectomy. No CSF leaks occurred.. This pilot study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during dural closures for craniotomies and transsphenoidal surgeries.

Topics: Adult; Aged; Aged, 80 and over; Allografts; Amnion; Brain Neoplasms; Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Craniotomy; Dura Mater; Endoscopy; Female; Glioma; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Neurilemmoma; Nose; Pilot Projects; Postoperative Complications; Reoperation; Retrospective Studies; Skull Base Neoplasms; Supratentorial Neoplasms; Wound Closure Techniques; Young Adult

In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.

Topics: Adolescent; Adult; Aftercare; Aged; Cerebrospinal Fluid Rhinorrhea; Child; Epistaxis; Female; Humans; Male; Middle Aged; Nasal Lavage; Nasal Mucosa; Nasal Septal Perforation; Nasal Surgical Procedures; Natural Orifice Endoscopic Surgery; Nose; Nose Diseases; Olfactory Nerve Diseases; Paranasal Sinuses; Pituitary Neoplasms; Postoperative Complications; Recovery of Function; Retrospective Studies; Rhinitis, Atrophic; Sphenoid Sinus; Sphenoid Sinusitis; Tissue Adhesions; Young Adult

Spontaneous cerebrospinal fluid (CSF) fistulas are infrequent and only 10 cases in the literature have been located in the clivus. We describe two new cases of CSF fistulas in this site and review the literature.. The first patient was a 52-year-old woman referred to our centre for intermittent rhinorrhea that had been diagnosed after an episode of meningitis. The second case was a 69-year-old man who was visited for rhinorrhea of one-year duration; he also developed meningitis during the preoperative study. In both cases, the spontaneous CSF fistula was diagnosed by beta-2-transferrin testing, CT scan and MRI. We performed an endonasal endoscopic transsphenoidal approach and used free grafts and vascularized flaps to close the clival defect. Treatment was successful in both cases.. The physiopathology of spontaneous CSF fistulas remains unknown. Possible explanations given to date in this location are pulsatility of the basilar artery, repeated Valsalva maneuvers and Marfan's disease, the two latter also related to CSF fistulas in other locations. Closure of a CSF leak towards the nasal cavity is mandatory due to potential complications. Our results support the endoscopic transsphenoidal approach using free grafts and/or pediculated flaps as a good alternative to open surgery.

Topics: Aged; Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Cranial Fossa, Posterior; Female; Fistula; Humans; Magnetic Resonance Imaging; Male; Meningitis; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Surgical Flaps; Tomography, X-Ray Computed; Treatment Outcome

The endoscopic endonasal approach is considered an alternative minimally invasive approach for suprasellar craniopharyngiomas. However, the complicated surgical manipulations required by this approach have limited its application. We evaluate whether the approach features a learning curve. Thirty-three patients were retrospectively reviewed and grouped as early (17 patients) and late (16 patient) groups. The operation time, extent of removal, ophthalmology, endocrinology, reconstruction and modifications of standard technique were evaluated. Between the two groups, the operation time decreased from 201.1±105.3min in the early group to 107.6±90.0min in the late group (p<0.05). Regarding clinical outcomes, non-significantly increasing trends toward the rate of gross total resection, visual improvement and (from 76.5% to 87.5%, 73.3% to 93.3%), significantly decreasing trends toward the rate of tumor recurrence (from 23.5% to 0% p<0.05) and non-significantly decreasing trends toward the rate of hypopituitarism recovery (26.7% to 0%) were observed between the two groups. With respect to complications, non-statistically significant decreasing trends toward transient cranial nerve paralysis (from 5.9% to 0%) and non-statistically significant increasing trends toward rate of CSF leakage, meningitis and new hypothyroidism (from 11.8% to 25%, 11.8% to 31.3%, 0 to 3%) were observed. We identified a learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. The exact number of patients necessary to establish a significant improvement in the clinical outcomes and decrease in the complications warrants further investigation. The outcomes of tumor recurrence may be associated with duration of follow-up. The CSF leakage represented the most common complication.

Topics: Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Female; Humans; Learning Curve; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications

Spontaneous cerebrospinal fluid (CSF) leaks represent a clinical entity in which CSF rhinorrhea occurs in the absence of any inciting event. Spontaneous CSF leaks are associated with elevated intracranial pressure (ICP) or have underlying idiopathic intracranial hypertension (IIH). We report a cohort of patients who have undergone nasal endoscopic repair for spontaneous CSF leaks. We review our perioperative complications and the effectiveness of the nasal endoscopic approach to repair spontaneous CSF leaks. Also, we examine the evidence correlating spontaneous CSF leaks and IIH and the role of decreasing ICP in the treatment of nasal spontaneous CSF leaks. A retrospective analysis of patients with nasal spontaneous cerebrospinal fluid leaks was performed. Data on the nature of presentation, patient body mass index, defect location and size, ICP, clinical follow-up, and complications were collected. Thirty-five patients had nasal spontaneous cerebrospinal fluid leaks with evidence of IIH's symptoms. The most common sites were the cribriform plate, the ethmoid roof, and sphenoid lateral pterygoid recess. All patients underwent endonasal endoscopic surgery to repair the defect. Postoperatively, all patients underwent lumbar drainage and acetazolamide therapy. Nasal spontaneous cerebrospinal fluid leaks represent a surgical challenge because of their high recurrence rates. The most important factor for obtaining a successful repair in these patients is reducing their intracranial pressure through nutritional, medical, or surgical means.

Topics: Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Drainage; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pseudotumor Cerebri; Retrospective Studies

Microscopic transnasal transsphenoidal surgery (MTTS) has been a time-confirmed effective treatment for pituitary adenomas; however, the data supporting its use in pediatric patients is limited. In this study, the authors summarize the authors' 5-year experience of pituitary adenomectomy via MTTS in a pediatric population. The authors retrospectively reviewed the medical records of 35 patients aged ≤18 years who underwent microscopic transnasal transsphenoidal approach for pituitary adenomas between January 2011 and December 2015. Age, sex, symptoms, tumor size, extent of tumor resection, surgical outcomes, and complications were reviewed. All patients underwent MTTS 39 times. Total resection was obtained in 31 (88.6%) patients, while subtotal resection was achieved in 4 (11.4%) and no patient had partial resection. For the 21 patients with preoperative visual impairment, 18 (85.7%) resolved and 3 (14.3%) obtained subjective improvement. Of the 33 patients with preoperative hyperhormonal levels, endocrine function reduced to normal reference range in 28 (84.8%), decreased in 3 (9.1%) and 2 (6.1%) patients had no change. Diabetes insipidus occurred in 4 (11.4%) patients, of whom 1 patient (2.9%) developed persistent diabetes insipidus that was treated with Minirin. One patient incurred postoperative cerebrospinal fluid leakage that was resolved by lumbar drainage. Hypopituitarism occurred in 3 patients, of whom 1 patient developed permanent hypopituitarism that required hormone replacement therapy. There were no patients of death, intracranial hematoma, or meningitis. In conclusion, MTTS is a safe and effective surgical option for pediatric pituitary adenomas with minimal morbidity and excellent outcomes.

Topics: Adenoma; Adolescent; Cerebrospinal Fluid Rhinorrhea; Child; Diabetes Insipidus; Female; Humans; Hypopituitarism; Male; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Sinus; Treatment Outcome; Vision Disorders

The primary objective was to assess the remission rate, and the secondary objectives were to evaluate the early complications and recurrence rate and to define the predictive factors for the remission and recurrence rates.. This prospective single-center study included 230 consecutive patients, operated on by a single surgeon for Cushing's disease via a transsphenoidal endoscopic endonasal approach, over a 6-year period (2008-2013). The patients included in this series were all adults (>18 years of age), who presented with clinical and biological characteristics of Cushing's disease confirmed based on dedicated MRI pituitary imaging. Biochemical remission was defined as a postoperative serum cortisol level <5 μg/dl on the 2nd day following surgery that required glucocorticoid replacement therapy.. The remission rate for the global population (n = 230) with a follow-up of 21 ± 19.2 months concerned 182 patients (79.1%) divided into 132 patients (82.5%) with positive MRI and 50 patients (71.4%) with negative MRI with no statistically significant difference (p = 0.077). Complications occurred in 77 patients with no deaths. A total of 22% of patients had transient diabetes insipidus and 6.4% long-term diabetes insipidus, and no postoperatively CSF leakage was observed. The recurrence rate was 9.8% with a mean time of 32.7 ± 15.2 months. The predictive factors for the remission rate were the presence of pituitary microadenoma and a positive histology. No risk factors were involved regarding the recurrence rate.. Whatever the MRI results, the transsphenoidal endonasal endoscopic approach remains the gold standard treatment for Cushing's disease. It was maximally effective with a remission rate of 79.1% and lower morbidity.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Diabetes Insipidus; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary ACTH Hypersecretion; Postoperative Complications

The incidence of traumatic CSF has increased in recent years due to increased incidence of road traffic accidents (RTA) as well the increasing number of endoscopic sinus surgeries (ESS). The objective of this study is to present our experience in management of traumatic CSF leaks using the endoscopic multilayer repair technique. Forty-two patients (aged 10-75 years, 30 males and 12 females) presenting with confirmed post-traumatic CSF rhinorrhea were operated upon between January 2007 and December 2013. The endoscopic multilayer technique was used in all cases. Electromagnetic navigation was used in some cases. All cases presented with intermittent watery rhinorrhea. The duration of the rhinorrhea ranged from 3 days to 1 year before repair. One case presented after 10 years from the causative trauma. Ten cases had a history of meningitis. Nine cases had more than one defect. Iatrogenic defects were larger than defects following accidental trauma. Two cases, following RTA, developed pseudo-aneurysm of internal carotid artery. Ten cases had associated pneumocephalus. The mean duration of postoperative hospitalization was 6 days (range 4-8 days). The mean follow-up duration was 31.2 +/- 11.4 months (range 16-48 months). None of our patient developed serious intra- or postoperative complications. Only one case required another surgery to repair a missed second defect. Post-traumatic CSF leaks can be successfully managed via the endonasal endoscopic route using the multilayer repair technique. It is important to look for multiple defects in these cases. CT angiography is recommended for traumatic leaks involving the lateral wall of the sphenoid sinus to diagnose or exclude the development of pseudo-aneurysm of the internal carotid artery.

Topics: Accidents, Traffic; Adolescent; Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Egypt; Female; Humans; Incidence; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Postoperative Complications; Radiography; Retrospective Studies; Skull Base; Sphenoid Sinus; Surgery, Computer-Assisted; Treatment Outcome

Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives.. All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging.. The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26-73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4-167) each patient is in good clinical condition with no further episodes of leaking or seizures.. Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure.

Topics: Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Encephalocele; Epilepsy; Female; Headache; Humans; Incidental Findings; Magnetic Resonance Imaging; Male; Meningitis; Meningocele; Middle Aged; Neuroendoscopy; Nose; Retrospective Studies; Sphenoid Sinus; Tomography, X-Ray Computed

In case of dehiscenses developing on the anterior scull base, complete closure resulting in the cessation of the communication between the nasal cavity and the intracranial space is mandatory as soon as possible, in order to prevent serious complications. With the development of the endoscopic techniques, the endonasal management for the reconstruction has become available in recent decades.. We aim to present the reconstruction techniques applied in our department in the cases of two patients recently operated at our institute. The choice of methods primarily depends on the size and the localization of the defect. Dehiscenses under 5 mm of diameter can be closed with the so called "bath-plug" technique, while bigger defects, where the required closure of the plug is not possible, can be solved with multilayer reconstruction. We use autogenous fascia, fat and muco-periosteum in both cases.. Our patient, who underwent the aforementioned "bath-plug" procedure, could be discharged after a few days of uneventful postoperative period. During a ten-month follow-up period new fistula formation was not observed. In the case of a patient who underwent multilayer reconstruction, meningitis occurred postoperatively, which was resolved after antibiotic therapy. During a 17-month follow-up period recurrent liquorrhoea did not occur.. With suitable technical background and appropriate endoscopic skills the surgeries of the anterior skull base cerebrospinal fluid fistulas can be performed efficiently and with low complication rate. These are minimally invasive procedures accompanied by less surgical trauma, morbidity and shorter hospitalization, hence these techniques are considered to be cost-effective and well-tolerated for the patients.

Topics: Cerebrospinal Fluid Rhinorrhea; Cost-Benefit Analysis; Female; Fistula; Humans; Hungary; Length of Stay; Male; Middle Aged; Neuroendoscopy; Nose; Plastic Surgery Procedures; Skull Base

In this study, we investigated the value of three-dimensional (3D) fast-imaging employing steady-state acquisition (FIESTA) magnetic resonance imaging (MRI) in detecting non-iatrogenic cerebrospinal fluid (CSF) rhinorrhoea and compared it with regular MRI and 3D magnetisation prepared rapid acquisition gradient echo (MPRAGE) MRI sequences, as well as high-resolution computed tomography (HRCT) imaging. We also present the endoscopic experiences of such cases.. From June 2011 to Feb 2016, 17 patients with non-iatrogenic cerebrospinal fluid rhinorrhoea were included. Seven patients had spontaneous rhinorrhoea, three patients had invasive tumours, and the remaining patients had traumatic aetiologies. All the patients underwent HRCT, regular MRI sequence imaging, 3D-MPRAGE MRI sequence imaging and 3D-FIESTA MRI sequence imaging for the preoperative evaluations of the leakages. For each patient, the CSF fistula site was confirmed by intraoperative neuronavigation and endoscopic findings. Statistical analyses were performed. All patients underwent endoscopic multilayer repair.. The sensitivities of the HRCT, regular MRI (T1 and T2), 3D-MPRAGE and 3D-FIESTA modalities for identifying CSF leakage were 58.8 %, (11.8 % and 29.4 %), 74.7 %, and 88.2 %, respectively. The origins of the leakages included the cribriform plate (18 %), ethmoidal fovea (23 %), lateral recess of the sphenoid (17 %), sellar floor (12 %), ethmoidal roof (12 %), junction of the fovea and cribriform plate (6 %) and the junction of sellar and sphenoidal planum (6 %). Two patients required repair. The first was under local anaesthesia when the nasal packing was removed, and the second underwent repair at the same site a half-year later due to hydrocephalus. Lumbar drainage was performed in all cases. No major complications were encountered.. The endoscopic endonasal approach is safe and effective for the treatment of CSF rhinorrhoea. The 3D-FIESTA MR modality is superior to 3D-MPRAGE MR and HRCT in the depiction of the CSF fistula site. Due to its non-invasive and reliable properties, 3D-FIESTA MR should be the preferred preoperative examination for the patients with non-iatrogenic CSF rhinorrhoea.

Topics: Cerebrospinal Fluid Rhinorrhea; Female; Humans; Imaging, Three-Dimensional; Magnetic Resonance Imaging; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Tomography, X-Ray Computed

Neuroendoscopic endonasal approach has gained popularity in managing traumatic, spontaneous, and especially iatrogenic cerebrospinal fluid (CSF) rhinorrhea. The authors examined 8 patients presenting with CSF rhinorrhea between December 2012 and June 2014: 5 patients had iatrogenic leak, 2 patients had traumatic leak, and 1 patient had a spontaneous onset of CSF rhinorrhea. Sites of the CSF leaks were detected through computed tomographic cisternography and magnetic resonance imaging in the patients with traumatic and spontaneous leaks. All patients received neuroendoscopic endonasal surgery for the CSF leak. The largest defect was 22 mm in maximum diameter. Endoscopic supraciliary "keyhole" approach was performed in 1 patient after confirmation of a frontal sinus leak using the endoscopic endonasal approach. The success rate was 100% in the first attempt. Follow-up period ranged from 3 to 24 months, and no recurrence was reported. Identifying the leak site and choosing the appropriate surgical technique remain the most important factor in surgical success.

Topics: Adipose Tissue; Adult; Aged; Cerebral Ventriculography; Cerebrospinal Fluid Rhinorrhea; Fascia Lata; Female; Follow-Up Studies; Frontal Sinus; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Muscle, Skeletal; Nasal Mucosa; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Tomography, X-Ray Computed; Treatment Outcome

To investigate the therapeutic effects of the image navigation system in nasal endoscopic surgery in treatment of basicranial tumor.. Retrospective analysis was carried out in 17 patients with basicranial tumor who underwent nasal endoscopic resection via image navigation system. The accuracy of image navigation system, operation procedure time, curative effect and complications were analyzed and summarized to evaluate the effect.. The image navigation system provided an accurate anatomical localization 0.5-2.0 mm localization error (mean 1.2 mm). The operation procedure time was 1.5-3.0 h. Postoperative complications occurred in 3 of 17 patients including cerebrospinal fluid rhinorrhea and injury of sieve plate. Two patients recrudesce within half a year.. The image navigation system in combination with a nasal endoscope is helpful in the resection of basicranial tumor with minimal trauma, increasing the curative effect and avoiding complications.

Topics: Cerebrospinal Fluid Rhinorrhea; Endoscopy; Humans; Nasal Surgical Procedures; Neoplasm Recurrence, Local; Neoplasms; Nose; Postoperative Complications; Retrospective Studies; Skull Base; Surgery, Computer-Assisted

To explore the mimic Valsalva maneuver with the help of a saccule handled by an anesthesiologist in order to locate the leakage channel and repair the fistula during intranasal endoscopic reconstruction surgery of cerebrospinal fluid rhinorrhea.. From 2012 to 2014, 8 patients were diagnosed with cerebrospinal fluid rhinorrhea by medical histories, physical and biochemical examination. All patients were treated with intranasal endoscopic reconstruction surgery of cerebrospinal fluid rhinorrhea. During the surgery, the mimic Valsalva maneuver with the help of a saccule was carried out once or twice by an anesthetist during the operation. Intranasal endoscopy was used to accurately locate the leakage site as shown by the exact fistula. Temporal fascia, fascia lata, middle turbinate mucosa and nasal septum mucosa were all used to repair the fistula.. After the surrounding mucosa was removed, the exact leakage sites were accurately found. Fascia materials were used in all 8 patients. All patients were successfully treated after their first operation, and 1 patient was successfully treated by two operations with no complications and recurrences. All the patients were followed up for 1 month to 2 years.. The convenient method of the mimic Valsalva maneuver with the help of a saccule handled by an anesthesiologist has a good prospect in cerebrospinal fluid rhinorrhea reconstruction surgery.

Topics: Adolescent; Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Child; Female; Follow-Up Studies; Humans; Intraoperative Period; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Plastic Surgery Procedures; Retrospective Studies; Saccule and Utricle; Time Factors; Tomography, X-Ray Computed; Valsalva Maneuver; Young Adult

To Summarize and analyze the clinical characteristics and treatment of patients with spontaneous cerebrospinal fluid rhinorrhea, and to explore the related factors of recurrence.. Retrospective- ly analyze the clinical data of 58 patients of spontaneous cerebrospinal fluid rhinorrhea from July 2002 to July 2012, combined with its clinical characteristics, and statistically analyze the related recurrence factors.. Fifty-eight cases were accepted the nasal endoscopic repairment of cerebrospinal fluid rhinorrheak, follow-up 3 years, 20 cases (34.5%) recurred, 1 case recurred in half a year after operation. In the first year, there were 10 cases recurred. In the second year there were 9 cases recurred, and 1 case recurred in the third year. Through multiariable analysis it was found that higher BMI, empty sella and skull base bone defect were the independent risk factors influencing the recurrence of spontaneous cerebrospinal fluid rhinorrhea (P < 0.05).. The recurrence rate of spontaneous cerebrospinal fluid rhinorrhea is high, needing long-term follow-up. Higher BMI, empty sella, skull base bone defect are independent risk factors of recurrence of the disease, and the treatment should be individualized.

Topics: Cerebrospinal Fluid Rhinorrhea; Empty Sella Syndrome; Endoscopy; Humans; Nose; Recurrence; Retrospective Studies; Risk Factors; Skull Base

Endoscopic endonasal skull base surgery defects require effective reconstruction. Although the nasoseptal flap (NSF) has become our institution's workhorse for large skull base defects with cerebrospinal fluid (CSF) leaks, situations where it is unavailable require secondary flaps. Clinical outcomes, pearls and pitfalls, and an algorithm will be presented for these secondary flaps.. Clinical case series.. Medical records of all endoscopic endonasal skull base surgeries at a tertiary care academic medical center were reviewed for skull base defect type, reconstruction method, CSF leak rate, and flap necrosis rate.. Of 330 flaps for reconstructing endoscopic endonasal skull base defects, secondary flaps were used in 34 cases (10%). These included 16 endoscopic-assisted pericranial flaps, seven tunneled temporoparietal fascia flaps, three inferior turbinate flaps, two middle turbinate flaps, two anterior lateral nasal wall flaps, two palatal flaps, one occipital flap, and one facial artery buccinator flap. There were 19 anterior cranial fossa defects, 10 clival defects, three sellar defects, and one frontal and one lateral orbit/middle fossa defect. Twenty-five of the 34 cases (73.5%) had either prior or postoperative radiation therapy. The most common pathology was sinonasal cancer, with 16 cases (47.1%). The postoperative CSF leak rate was 3.6% due to one middle turbinate flap necrosis.. Secondary flaps for skull base reconstruction can be harvested with minimally invasive techniques and demonstrate excellent success rates (97%) that are comparable to that of the NSF (>95%). Multiple flaps for complex skull base defects should be in the armamentarium of comprehensive skull base surgery centers.. 4.

Topics: Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Follow-Up Studies; Humans; Nasal Mucosa; Nasal Septum; Natural Orifice Endoscopic Surgery; Nose; Plastic Surgery Procedures; Retrospective Studies; Skull Base; Surgical Flaps; Treatment Outcome

Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas.. The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated.. The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3-246 months).. The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Craniopharyngioma; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome; Young Adult

Topics: Adenoma; Cerebrospinal Fluid Rhinorrhea; Humans; Intraoperative Period; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Period; Sphenoid Bone

Endoscopic endonasal transplanum transtuberculum (EETT) resection of parasellar skull base (SB) tumors often results in large SB defects with intraoperative high-flow cerebrospinal fluid (CSF) leaks. Reconstruction of these defects can be challenging because of the large defects size, communication with the suprasellar cistern, and close proximity to the optic nerves and chiasm. Recent studies have postulated that transplanum defects may be associated with increased postoperative CSF leakage. We review our experience with reconstruction of transplanum defects after EETT resection of parasellar SB tumors. Challenges encountered during these repairs and our operative nuances for successful reconstruction are discussed.. A retrospective analysis was performed between March 2010 and February 2012 on patients undergoing reconstruction of transplanum defects after EETT resection of parasellar SB tumors. Repair materials, defect sizes, postoperative CSF leakage, postoperative CSF diversion, and demographic data were collected.. Nineteen patients who underwent 22 repairs with a pedicled nasoseptal flap (PNSF) were identified. The mean age was 47.6 years (range, 12-68 years). Average defect size was 5.6 cm(2) (range, 2.2-10.4 cm(2)). Three failed repairs necessitated a revision procedure. All three revisions were successfully reconstructed with the previously used PNSF. The mean follow-up period was 13.5 months (range, 1-26 months). The overall success rate was 86.4% for transplanum defects alone, as compared to 97.0% for our comprehensive PNSF experience in 99 repairs.. Repair of large transplanum defects after EETT resection of parasellar SB tumors presents a unique challenge. Using a PNSF along with meticulous multilayer closure may help decrease postoperative CSF leaks.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Child; Endoscopy; Fascia Lata; Female; Follow-Up Studies; Humans; Imaging, Three-Dimensional; Magnetic Resonance Imaging; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Plastic Surgery Procedures; Retrospective Studies; Sella Turcica; Skull Base Neoplasms; Surgical Flaps; Tomography, X-Ray Computed; Transplantation, Autologous; Treatment Outcome; Young Adult

To assess long-term efficacy of the gasket seal, a method for watertight closure of the cranial base using autologous fascia lata held in place by a rigid buttress, in a large case series.. A prospectively acquired database of all endonasal endoscopic surgeries performed over a 5-year period at Weill Cornell Medical College starting in September 2005 was reviewed.. The gasket seal was used in 46 consecutive patients. Mean age was 53 years (range 7-83 years). All patients had extensive intracranial disease with a significant intraoperative cerebrospinal fluid (CSF) leak. Pathology included craniopharyngioma (39.1%), meningioma (23.9%), and pituitary adenoma (17.4%). After a mean follow-up of 28 months (range 3-63 months), two (4.3%) patients had a postoperative CSF leak. Excluding the patients with adenomas, the CSF leak rate was 5.2% (2 of 38 patients). One leak was controlled with reoperation, and the other was stopped with a lumbar drain (LD). The significance of pathology, type of approach, exposure of the ventricular system, use of fat graft, use of nasoseptal (NS) flap, and use of lumbar drain (LD) was examined, and none of these were significant predictors of postoperative CSF leak.. Gasket seal closure is a reliable long-term effective method for achieving watertight closure of the cranial base. It can be used in association with an intracranial fat graft, NS flap, LD, and tissue sealants. In this series, none of these other factors were significant predictors of postoperative CSF leak.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Child; Databases, Factual; Female; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Neuroendoscopy; Nose; Postoperative Complications; Skull Base; Skull Base Neoplasms; Wound Closure Techniques; Young Adult

The skull base is an intricate interface between the cranium and face allowing the passageway of vital structures. Anatomic conceptualization forms the platform for surgical approaches and solutions to skull base pathology. Understanding embryogenesis provides further depth into the pathophysiology of congenital defects. This chapter aims to highlight skull base anatomy and embryology along with cerebrospinal fluid physiology and diagnostic evaluation of cerebrospinal fluid leaks.

Topics: Cerebrospinal Fluid Rhinorrhea; Diagnosis, Differential; Endoscopy; Humans; Intracranial Pressure; Magnetic Resonance Imaging; Nose; Physical Examination; Pneumoencephalography; Prognosis; Skull Base; Tomography, X-Ray Computed

To study the feature and treatment method of patients with empty sella merger cerebro-spinal fluid leakage of nasal.. There were 8 cases with empty sella merger cerebrospinal fluid leakage of nasal, 2 cases were accepted the repairing surgery of cerebrospinal fluid leakage one time, 4 cases were accepted the repairing surgery of cerebrospinal fluid leakage used endoscope 2 times, 1 case was accepted repairing surgery of cerebrospinal fluid leakage used endoscope merge craniotomy and ventricle celiac bypass, 1 case recurrences after repairing surgery of cerebrospinal fluid was recurred after conservative treatment. Some postoperative were stayed in bed for three weeks and lumbar drainage for 1 week.. One case of cerebral hemorrhage after surgery was cured with craniotomy, followed for 2 years without recurrence. One case was recurred after conservative treatment. Two cases recurrences after surgery 3 years ago were accepted surgery again followed by one year without recurrence. One case who recurrence 1 year later was accepted repairing surgery of cerebrospinal fluid leakage used endoscope merge craniotomy and ventricle celiac bypass followed six months without recurrence. One cash after once surgery was followed half a year without recurrence. One case with recurrence 5 years later was accepted repairing surgery again.. The patient with empty sella combined cerebrospinal fluid leakage of nasal was rare, the main method was endoscopic sinus surgery treatment, but it recurred usually. The patients with repeatedly recurrence can be considered to accepted the surgery of ventricle celiac bypass. It required long-term postoperative follow-up and review.

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Empty Sella Syndrome; Endoscopy; Female; Humans; Male; Middle Aged; Nose

In our study, pedicled nasal flap (NF) did not provide better results than free nasal graft (NG) for primary closure of cerebrospinal fluid (CSF) rhinorrhea. In the future, a multicenter randomized study would be needed to confirm this result. The choice of surgical technique will depend on the surgeon's experience, and the position and size of the defect.. To evaluate our results in repairing CSF leaks, comparing the two techniques we used: free NG and pedicled NF.. A total of 33 patients diagnosed with CSF rhinorrhea were operated on between June 2000 and May 2010; 17 were women. The mean age was 44.7 years (± 13.0). Twenty-two (66.6%) NFs of the middle and lower turbinate and septum were performed, the rest being NGs of the middle and lower turbinate only. A descriptive statistical analysis and a Kaplan-Meier survival analysis were carried out and the log-rank statistic was used to compare both techniques.. In the present study, 78% of defects were closed in all cases; NF was used in 86% (19) and NG in 63.63% (7). The mean follow-up was 71.5 (95% confidence interval (CI), 56.9-86.1) months. There were no statistically significant differences (p > 0.05).

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Female; Humans; Male; Middle Aged; Nasal Surgical Procedures; Nose; Retrospective Studies; Surgical Flaps

The removal of hypophyseal tumor by transsphenoidal pituitary surgery using microsurgical instruments was first performed over 100 years ago. Operating techniques for this surgery are constantly being renewed, first by using a microscope and later on with the use of an endoscop. The authors provide an overview of the minimal invasive posterior transseptal-transsphenoidal aproach with the combined utilization of classical techniques with the assistance of the endoscop.. Sixty-one patients (33 female, 28 male, 21-84 yrs) were treated for sellar region tumor resection using an endonasal transsphenoidal aproach with the help of an endoscope. Follow ups were performed within 2-21 months.. Total tumor resection was successful in 91.8%, and partial resection in 8.2% of the patients. The rate of complications using the endoscopic method was not higher compared to that of the classical microscopic method. There was no major bleeding in any of the cases. Adverse events such as minor epistaxis occurred in 4.9%, transitional diabetes insipidus in 6.5%, inraoperative CSF leak in 16.67%, postoperative CSF leak in 11.5% and meningitis in 8.2% of the patients. After the operation the pathological hormonal production stoped in all patients except in two patients who were acromegalic. However their GH level normalized and they did not require further treatment, the IGF-1 still remained high.. The success of the surgical treatment is based on both, the proficient pre- and postoperative endocrinological care, and the minimal invasive surgical technique. The endoscope was used partially or continuously during the operation for better visualization of the operation field in multiple angles (30 degrees, 45 degrees). It was useful in differentiating between normal and tumorous glandular tissue, and also offered an enhanced view of the intrasellar (via hydroscopy) and parasellar region. Moreover the endoscopic method is able to decrease the operating time, reduce blood loss. In different stages of the surgery, depending on the anatomical and pathological situation, switching back and forth from microscope to endoscope technique, gives us the benefit of a clearer view in each situation.

Topics: Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Diabetes Insipidus; Epistaxis; Female; Humans; Learning Curve; Male; Meningitis; Middle Aged; Neuroendoscopes; Neuroendoscopy; Nose; Pituitary Gland, Posterior; Pituitary Neoplasms; Sphenoid Sinus

The authors reviewed the medical records of patients who had undergone endoscopic endonasal craniotomy in our department between 2005 and 2009. Thirteen patients were included in this study: 12 males and 1 female. Patients were affected by ethmoidal malignancies abutting or involving the anterior skull base. In all the patients the anterior skull base was drilled down. Nine patients underwent dural resection. The procedure always included a skull base reconstruction. Postoperative complications included CSF leak, subdural haematoma and pneumocephalus. Our results show that endoscopic endonasal surgery can be a viable alternative to anterior craniofacial resection in the management of selected ethmoidal malignancies. The limited morbidity and high success rate fit well with the data in the literature and make this treatment option advisable.

Topics: Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Craniotomy; Diagnostic Imaging; Dura Mater; Endoscopy; Ethmoid Sinus; Female; Follow-Up Studies; Hematoma, Subdural; Humans; Male; Middle Aged; Neoplasm Staging; Nose; Paranasal Sinus Neoplasms; Plastic Surgery Procedures; Pneumocephalus; Postoperative Complications; Radiotherapy, Adjuvant; Retrospective Studies; Skull Base; Treatment Outcome

The development of endoscopic endonasal approaches, albeit in the early stages, represents part of the continuous evolution of skull base surgery. During this early period, it is important to determine the safety of these approaches by analyzing surgical complications to identify and eliminate their causes.. The authors reviewed all perioperative complications associated with endoscopic endonasal skull base surgeries performed between July 1998 and June 2007 at the University of Pittsburgh Medical Center.. This study includes the data for the authors' first 800 patients, comprising 399 male (49.9%) and 401 female (50.1%) patients with a mean age of 49.21 years (range 3-96 years). Pituitary adenomas (39.1%) and meningiomas (11.8%) were the 2 most common pathologies. A postoperative CSF leak represented the most common complication, occurring in 15.9% of the patients. All patients with a postoperative CSF leak were successfully treated with a lumbar drain and/or another endoscopic approach, except for 1 patient who required a transcranial repair. The incidence of postoperative CSF leaks decreased significantly with the adoption of vascularized tissue for reconstruction of the skull base (< 6%). Transient neurological deficits occurred in 20 patients (2.5%) and permanent neurological deficits in 14 patients (1.8%). Intracranial infection and systemic complications were encountered and successfully treated in 13 (1.6%) and 17 (2.1%) patients, respectively. Seven patients died during the 30-day perioperative period, 6 of systemic illness and 1 of infection (overall mortality 0.9%).. Endoscopic endonasal skull base surgery provides a viable median corridor based on anatomical landmarks and is customized according to the specific pathological process. This corridor should be considered as the sole access or may be combined with traditional approaches. With the incremental acquisition of skills and experience, endoscopic endonasal approaches have an acceptable safety profile in select patients presenting with various skull base pathologies.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Retrospective Studies; Skull Base; Treatment Outcome

The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base.. A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009.. The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted.. Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.

Topics: Adipose Tissue; Adolescent; Adult; Aged; Cerebrospinal Fluid Leak; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Endoscopy; Ethmoid Sinus; Feasibility Studies; Female; Follow-Up Studies; Free Tissue Flaps; Frontal Sinus; Humans; Male; Middle Aged; Nose; Paranasal Sinuses; Recurrence; Reoperation; Retrospective Studies; Sella Turcica; Sphenoid Sinus; Surgery, Computer-Assisted; Surgical Flaps; Treatment Outcome; Young Adult

CT and MRI are helpful to detect the precise site of the fistula, which is crucial for carrying out the repair, and transnasal endoscopic surgery is an effective treatment for recurrent cerebrospinal fluid (CSF) rhinorrhea.. To discuss the cause and treatment of recurrent CSF rhinorrhea.. A retrospective study was undertaken to analyze the clinical characteristics of 32 patients with recurrent CSF rhinorrhea. After detailed examination and radiological evaluation by CT and MRI, all of them underwent transnasal endoscopic surgery.. Six patients presented a leakage at the posterior wall of the frontal sinus, 12 at the ethmoid roof, and 14 at the sphenoid roof. Four cases with a defect in the frontal sinus and frontal recess were repaired with the DRAF III procedure, four cases with a defect in the sphenoid lateral recess were repaired through transpterygoid intervention and under an image-guided navigation system, while the others were operated by routine endoscopic sinus surgery. No recurrence was found during the follow-up for 14-60 months (mean 36.8) in 31 cases, and 1 case with recurrence recovered well after further surgery.

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Female; Follow-Up Studies; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Nose; Recurrence; Retrospective Studies; Tomography, X-Ray Computed; Treatment Outcome; Young Adult

To summarize endoscopic management of cerebrospinal rhinorrhea and position-determining means.. Fifteen cases of cerebrospinal rhinorrhea treated by endoscopic approach at our institution were analyzed retrospectively. Aetiology included accidental trauma (10), surgical trauma (4), idiopathic (1). All patients presented with CSF rhinorrhea. Six cases were operated after failure of conservative treatment. Two cases after failure of neurosurgical repair were referred to our department. The largest defect was as big as 2.5 cm x 1.5 cm. All patients were scanned by computed tomography and magnetic resonance imaging and confirmed by biochemistry test. Ten patients received high resolution spiral computed tomography bonding ventriculography.. We performed intranasal endoscopic repair in all 15 patients. All repairs were successful at the first attempt with a mean follow up of 20 months. One patient had light headache postoperatively and relieved with conservative treatment. All defects of skull base detected by computed tomography and ventriculography were confirmed in the operation.. Intranasal endoscopic repair of cerebrospinal rhinorrhea can be an effective method. High resolution spiral computed tomography scan combined with ventriculography is a precise position-determining means. With the advancement of instrument and operative skill, the scope of endoscopic repair will further extend.

Topics: Adolescent; Adult; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Female; Humans; Male; Middle Aged; Nose; Retrospective Studies; Tomography, Spiral Computed; Young Adult

Aim of this report is to describe the long-term results of endoscopic endonasal repair of cerebrospinal fluid leak using a septal mucoperichondrial graft. A case series of 52 patients operated for cerebrospinal fluid rhinorrhea between 1990 and 2006 is presented. All patients underwent surgical treatment for endoscopic endonasal closure of a cerebrospinal fluid leak using a septal mucoperichondrial graft. No lumbar drain and fluorescein tests were used. The intra-operative localization of the fistula was aided by Valsalva's manoeuvre by the anaesthetist. The success rate, after the first attempt, was 88.5% (46/52 patients); for the remaining 11.5% (6/52 patients), a second attempt was necessary which proved successful in 5 cases, raising the overall success rate to 98.1% (51/52 patients). Relapse occurred in only one case (1.9%), after the second attempt. In conclusion, a free mucoperichondrial graft offered good results for cerebrospinal fluid leak repair. In the Authors' experience, a high success rate can be achieved without the use of intrathecal fluorescein and lumbar drain.

Topics: Adolescent; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Female; Fistula; Follow-Up Studies; Humans; Iatrogenic Disease; Male; Nasal Septum; Nose; Pituitary Neoplasms; Postoperative Complications; Severity of Illness Index; Sinusitis; Tomography, X-Ray Computed; Transplantation, Autologous; Valsalva Maneuver; Young Adult

Topics: Cerebrospinal Fluid Rhinorrhea; Craniotomy; Endoscopy; Frontal Sinus; Humans; Male; Nose; Plastic Surgery Procedures; Young Adult

Cerebrospinal fluid (CSF) leakage following endoscopic endonasal skull base resection can be a significant problem. A method for securing tissue grafts is needed. In this paper the authors used an endonasal suturing device to secure the graft reconstruction following endonasal tumor resection. The U-Clip anastomotic device (Medtronic), developed for cardiovascular anastomoses, was used to secure the tissue graft to native dura. A specialized needle driver and hemoclip applier were used for the application and deployment of this device. No suture tying was necessary, facilitating its endonasal application. The graft was successfully secured in its desired position to native dura by using the U-Clip anastomotic device. The patient did not suffer a postoperative CSF leak, and postoperative imaging and endoscopy revealed that the graft was in a good position. There was no complication from the use of the device. The U-Clip anastomotic device can be used as a suture device during endonasal surgery. It may prevent tissue graft migration and help prevent CSF leakage.

Topics: Biocompatible Materials; Cerebrospinal Fluid Rhinorrhea; Collagen; Dura Mater; Endoscopy; Equipment Design; Female; Humans; Meningioma; Middle Aged; Nose; Plastic Surgery Procedures; Postoperative Complications; Suture Techniques; Sutures

The authors reviewed their experience with endoscopic approaches to determine their safety and efficacy in the treatment of pediatric patients who harbor skull base lesions. Although they were interested in ascertaining outcomes after surgery as well as validating and defining indications and limitations of these approaches, the authors recognized that the follow-up duration was inadequate to assess long-term outcomes.. The authors conducted a retrospective review of all endoscopic procedures performed at their institution between January 2000 and September 2005. The procedures were categorized into a series of anatomical modular approaches. Twenty-five patients 18 years of age or younger were identified. The surgical goals were individualized and included gross-total resection, partial resection, biopsy, decompression of neural structures, and repair of a cerebrospinal fluid (CSF) leak. One patient required an open procedure in addition to the expanded endonasal approach for definitive therapy. No patient suffered a neurological deficit, vascular injury, or central nervous system infection. A CSF leak was the most common complication and occurred in two (8%) of the 25 patients.. In well-selected patients, the expanded endonasal approach represents a safe, effective, and minimally invasive technique for the treatment of skull base lesions in children. Incremental experience is needed for acquiring the skills with endoscopic techniques to progress to the more complex modular approaches.

Topics: Adolescent; Biopsy; Brain Diseases; Brain Neoplasms; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Craniotomy; Decompression, Surgical; Endoscopy; Female; Follow-Up Studies; Humans; Male; Nose; Postoperative Complications; Retrospective Studies; Safety; Skull Base; Treatment Outcome

The annual risk of meningitis in unrepaired fistulas is widely quoted to be approximately 10% per annum. Our aim was to review our experience with cerebrospinal fluid (CSF) leaks and to calculate the overall risk and the annual incidence of meningitis, and to correlate our findings with the causation and the effect of operative intervention in a subgroup of patients who had a history of meningitis.. We prospectively collected data on all patients referred with a CSF leak to our tertiary referral center over a 12-year period between 1994 and 2006. We had a follow-up rate of 91%.. One hundred eleven patients had a proven leak on endoscopy, beta-2 transferrin, imaging, and/or fluorescein lumbar puncture. The accumulated duration of an active CSF leak in the cohort was 190 years. The total number of episodes of meningitis was 57 in 21 patients, giving an overall risk of developing meningitis of 19%, with an overall incidence of 0.3 episodes per year. There was a progressive reduction in the incidence of meningitis with time, and most episodes occurred within the first year following the onset of the CSF leak. However, the risk persisted as long as the CSF leak was active.. The overall risk of meningitis in patients with persistent CSF rhinorrhea was 19%. The annual incidence of meningitis was 0.3 episodes per year, with most episodes occurring within the first year following the onset of the leak. Endoscopic closure is the treatment of choice in most CSF leaks; if successful, it reduces the risk of meningitis.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Endoscopy; Female; Follow-Up Studies; Humans; Incidence; Male; Meningitis; Middle Aged; Nose; Prognosis; Prospective Studies; Risk Factors

Cerebrospinal fluid (CSF) leakage is a critical condition with a substantial risk of meningitis. We investigated the use of transferrin isoform analysis as a diagnostic marker for detection of CSF leakage in fluid samples.. We analyzed 241 samples from patients with CSF leakage, most commonly presenting as otorrhea or rhinorrhea, by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) with subsequent Western blotting and immunostaining for transferrin. Tears, saliva, nasal fluid, and ear secretions (20 samples each) were analyzed in parallel, and normal human serum served as a control in each experiment. We compared the minimum volume of added CSF that could be detected in secretions by our assay with the minimum volume detected by the prostaglandin-D synthase (beta-trace) test. CSF was admixed with blood in different proportions to determine the influence of blood contamination on the transferrin pattern.. In all CSF samples, beta1- and beta2-transferrin were present in nearly equal amounts. In tears and ear secretions, beta2-transferrin migrated in the gel in the same manner as in CSF, but its concentration was noticeably lower than that of beta1-transferrin, a difference that allowed a clear distinction from the transferrin pattern of CSF. In saliva, both transferrin isoforms were also present but could be distinguished from those of other fluids by electrophoretic migration pattern rather than relative concentrations. With the beta-trace test, a minimum of 5 microL of CSF was needed for detection, whereas our beta2-transferrin assay yielded a signal of comparable intensity with a minimum of 2 microL of CSF.. Analysis of the transferrin microheterogeneity pattern by SDS-PAGE for the identification of CSF leakage is a highly sensitive and specific method that merits consideration as a routine technique.

Topics: Biomarkers; Cerebrospinal Fluid Otorrhea; Cerebrospinal Fluid Rhinorrhea; Ear; Electrophoresis, Polyacrylamide Gel; Humans; Nose; Protein Isoforms; Reproducibility of Results; Retrospective Studies; Saliva; Sensitivity and Specificity; Tears; Transferrin

To assess the feasibility of passive marker computer-aided surgery in a single institution, we performed 22 procedures in 21 patients with disorders including sinonasal tumors (n = 9), fungal sinusitis (n = 4), recurrent polyps (n = 3), chronic sinusitis (n = 3), and cerebrospinal fluid rhinorrhea (n = 2). Passive marker computer-aided surgery was successful in 19 of the 21 patients. The accuracy was on the order of 1.35 mm. Probe conversion, rotation, and cordlessness were helpful in all 19 cases. The system helped with landmarks (n = 14), margins (n = 7), skull base (n = 6), orbit (n = 5), and approach (n = 4). Computer-aided surgery accurately confirmed the location of an instrument and demonstrated tumor-normal tissue interfaces. It aided the surgeon in procedures on the sinonasal area and cranial base. The potential advantages of a passive marker system as compared with other available technologies center around the ability to convert and/or rotate virtually any instrument to a cordless imaging probe on demand during the operation.

Topics: Angiofibroma; Cerebrospinal Fluid Otorrhea; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Endoscopy; Humans; Magnetic Resonance Imaging; Meningeal Neoplasms; Meningioma; Nasopharyngeal Neoplasms; Nose; Otorhinolaryngologic Surgical Procedures; Paranasal Sinuses; Pituitary Neoplasms; Safety; Sinusitis; Skull Base; Surgery, Computer-Assisted; Tomography, X-Ray Computed

To observe the therapeutic effect of intranasal endoscopic repair on cerebrospinal fluid (CSF) rhinorrhea.. Messerklinger operative technique was followed. The affected uncinate process, ethmoid bulla was resected. The ethmoid sinus was open and the anterior skull base exposed. 0 degree, 30 degrees endoscope and suction were used to help localize fistula.. 10 cases were successfully repaired during the first attempt. Follow-up for four months to one year found no recurrence and not any complication.. Intranasal endoscopic repair of CSF rhinorrhea could afford excellent view, facilitate precise tissue graft placement and better recovery.

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Female; Follow-Up Studies; Humans; Male; Middle Aged; Nose

Surgical management of cerebrospinal fluid leaks (CSFL) has improved these few past years with the development of paranasal sinus surgery under optical guidance. CSFL localized in the sphenoid sinus represent only 5 to 15% of all CSFL. The authors have analyzed a serie of 15 patients having undergone surgery from 1992 to 1999 for CSFL: 10 cases followed pituitary gland surgery realized through sublabial-transsphenoidal approach, 2 cases followed head trauma, 1 case followed a secondary neurosurgical procedure following recurrence of a rathke's cleft cyst, 1 case followed medical treatment of a bulky pituitary gland adenoma and 1 case was associated to an empty sella syndrome. The surgical procedure has relied on sphenoid sinus approach through the sphenoethmoidal recess (SER) (n = 8), transethmoidal approach (TE) (n = 2) or transseptal approach (TS) (n = 7) followed by a filling of the defect by a graft of fat with biological glue (n = 17). Sometimes it was associated to a cartilagenous graft (n = 7) when there was a bone defect. The average period of hospitalisation was 5.2 days (4-21), mean follow-up was 2.9 years (6 months-7 years).. The success rate was 80% (3 failures were observed), 2 patients underwent secondary procedures by TS approach with success. Our results combined with the literature data led us to propose an alternative surgical strategy adapted to each case. Endonasal surgery under optic guidance compared to the transrhinoseptal approach represents an attractive alternative with less undesirable iatrogenic consequences.

Topics: Adipose Tissue; Adult; Algorithms; Cartilage; Cerebrospinal Fluid Rhinorrhea; Decision Trees; Endoscopy; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Nose; Reoperation; Retrospective Studies; Sphenoid Sinus; Tissue Adhesives; Tomography, X-Ray Computed; Treatment Outcome

Five patients with cerebrospinal fluid fistula (CFF) have been treated with intratecal fluoresceine, 2 cc at 2%, and endoscopic nasal surgery. In 3 patients CFF was postraumatic; one case spontaneous and another case iatrogenic. In all the cases CFF have been solved in the first time. Postoperatory follow-up vary from 8 to 14 months, and no recurrence was observed. Fluorescein must be managed adequately for prevent neural complications.

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Clinical Protocols; Endoscopy; Female; Humans; Male; Middle Aged; Nose

Surgery of the skull base and of the paranasal sinuses is often difficult because of the complex anatomy and the delicate structures; serious complications (loss of vision, cerebral lesion) have been reported. To improve the safety of such operations, computer-assisted navigation surgery is increasingly being put to use. We introduce the system which was developed in Berne. Our computer-assisted system is based on an intraoperative pursuit of the head and instruments which are equipped with infrared diodes and registered by an opto-electronic system-camera. The CT-acquisition of the head is accomplished framelessly without a head-holding device. This allows free movement of the head during surgery. Between March and November 1997, 35 navigation operations were performed for various pathologies at the anterior and lateral skull base. The majority of the cases were endonasal operations. No surgical complications occurred inspite of the complexity of the operations. The measured accuracy of the system between the CT and the actual instrument location in the patient was 0.5-2 mm (mean : < 1 mm) for the anterior skull base and 1-2.5 mm (mean < 1.5 mm) for the lateral skull base. The intraoperative navigation system allows identification of essential anatomical structures and permits safe and efficient surgery without additional loss of time. In addition, such a system allows minimal invasive approaches, and new operations may become possible.

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Computer Systems; Electronics, Medical; Endoscopes; Endoscopy; Ethmoid Sinus; Ethmoid Sinusitis; Female; Humans; Image Processing, Computer-Assisted; Intraoperative Care; Male; Middle Aged; Minimally Invasive Surgical Procedures; Nose; Optics and Photonics; Paranasal Sinuses; Radiology Information Systems; Safety; Skull Base; Sphenoid Sinus; Therapy, Computer-Assisted; Tomography, X-Ray Computed; User-Computer Interface

Blast injuries involving the frontobasilar region and orbit can present difficult evaluation and treatment challenges. This article presents the surgical treatment of four patients presenting with blast-type injuries involving the central periorbital region and anterior skull base. Three of these were the result of close-range gunshot wounds, and one was caused by an avulsive penetrating tree branch injury during a motor vehicle accident. All four patients underwent frontal craniotomy for exposure to repair significant intracranial injuries. Following intracranial repair of dural and brain injuries, anterior cranial fossa reconstruction was performed. In two of these patients, elective supraorbital osteotomies were performed to allow improved access to the posterior aspect of the anterior skull base. The healing period of all four patients has been without complications relative to the anterior fossa injuries.

Topics: Adult; Blast Injuries; Bone Transplantation; Brain Injuries; Cerebrospinal Fluid Rhinorrhea; Craniotomy; Dura Mater; Eye Injuries, Penetrating; Female; Follow-Up Studies; Frontal Bone; Humans; Male; Nose; Orbital Fractures; Osteotomy; Skull Base; Skull Fractures; Surgical Flaps; Surgical Mesh; Wound Healing; Wounds, Gunshot; Wounds, Penetrating

Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.

Topics: Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Endoscopy; Ethmoid Bone; Fascia; Female; Fibrin Tissue Adhesive; Follow-Up Studies; Humans; Intraoperative Complications; Magnetic Resonance Imaging; Male; Middle Aged; Muscle, Skeletal; Myelography; Nasal Mucosa; Nasal Septum; Nose; Nose Neoplasms; Reoperation; Retrospective Studies; Surgical Flaps; Tissue Adhesives; Tomography, X-Ray Computed; Turbinates

Topics: Accidents, Traffic; Alcoholic Intoxication; Anesthesia, Local; Cerebrospinal Fluid Rhinorrhea; Child; Contusions; Ecchymosis; Edema; Epistaxis; Frontal Bone; Hematoma; Humans; Nasal Bone; Nasal Septum; Nose; Orbital Fractures; Skull Fractures; Violence

Topics: Cerebrospinal Fluid Rhinorrhea; Collagen; Dura Mater; Endoscopes; Endoscopy; Humans; Nose; Postoperative Care

Nasal cerebral heterotopia is a congenital lesion that is mainly detected in early childhood. The rare cases of this disorder found in adult patients are located intranasally. A common symptom is compromised nasal air passage. Clinical findings include polypoid masses in either the nasal cavity or the paranasal sinuses. To our knowledge, primary cerebrospinal fluid (CSF) rhinorrhea has been reported only twice in these patients.. A 64-year-old female patient presented with CSF rhinorrhea proven by beta 2-transferrin testing. Previous head injury or intranasal manipulation were excluded. Anterior rhinoscopy revealed a watery drainage from the right middle meatus. CT scan showed a defect in the lateral roof of the right ethmoid sinus, approximately 5 mm in diameter; MRI revealed a mass in the right ethmoid and frontal sinuses, penetrating the anterior skull base. The lesion was resected by an extranasal approach. It showed a fibrous connection to the frontal lobe. Histologically, the lesion consisted of neural tissue composed of gray and white matter, both with a normal structuring. Dura and skull base were reconstructed. There were no signs of a CSF leak postoperatively.. The differential diagnosis of CSF rhinorrhea includes traumatic events and neoplasms, elevated intracranial pressure, and connate lesions as encephaloceles and, in rare cases, nasal cerebral heterotopia.

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Choristoma; Diagnosis, Differential; Female; Humans; Magnetic Resonance Imaging; Middle Aged; Nose; Nose Diseases; Tomography, X-Ray Computed

In most cases the surgical management of craniofacial fractures involves a correction of the occlusion. This requires nasal intubation. In a frontobasal fracture with simultaneous CSF fistula, nasal intubation is thought to increase the risk of meningitis. An analysis of the records of 160 patients with frontobasal fractures and CSF fistulae revealed that the route of intubation had no influence on the post-operative complication rate. Nasal intubation is therefore not contraindicated in frontobasal fractures with CSF fistulae.

Topics: Cerebrospinal Fluid Rhinorrhea; Contraindications; Frontal Bone; Humans; Intubation, Intratracheal; Meningitis, Pneumococcal; Nose; Skull Fractures

Topics: Adolescent; Cavernous Sinus; Cerebrospinal Fluid Rhinorrhea; Embolism, Air; Female; Humans; Meningitis, Haemophilus; Nose; Pressure; Thrombosis

A case of a complicated penetrating nasal injury is presented. The rapid diagnosis of cerebrospinal fluid rhinorrhea, with appropriate bedside tests and imaging techniques, is essential for the prevention of bacterial meningitis.

Topics: Cerebrospinal Fluid Rhinorrhea; Child, Preschool; Humans; Male; Meningitis, Pneumococcal; Nose; Skull Fractures

Topics: Adolescent; Cerebrospinal Fluid Rhinorrhea; Encephalocele; Humans; Male; Meningitis, Aseptic; Meningocele; Nose

Augmentation rhinoplasty has become a popular plastic operation in Asia. In Korea most surgeons prefer using silicone rubber prosthesis instead of autogenous material. The authors have used the standard shaped silicone prosthesis, boat-shaped and also L-shaped prostheses. The standard shape prosthesis has less extrusion and fixation problems. In over 1,500 cases, there were 357 complications (20.8%). All the complications were due to the silicone prosthesis acting as a foreign body or failure in design of implant or unskillful operative technique. In order to minimise complications, care should be taken to use the proper size of prosthesis, the correct shape of implant and to ensure that there is adequate undermining and meticulous closure technique. To minimise the overlying skin tension at the tip and on the dorsum of the nose, the cutting of the depressor septi nasi muscle and transverse part of the nasalis muscle are recommended. In this review, we report the types and incidence of complications by analysing the cases seen during the past 10 years in our Unit and offer a few solutions to overcome these complications.

Topics: Asian People; Cerebrospinal Fluid Rhinorrhea; Enterobacteriaceae Infections; Epistaxis; Erythema; Humans; Korea; Nose; Postoperative Complications; Prostheses and Implants; Rhinoplasty; Serratia marcescens; Silicone Elastomers; Staphylococcal Infections; Staphylococcus aureus; Surgical Wound Infection; Time Factors

Naso-orbital trauma can cause medial orbital wall disruption and detachment of the medial canthal ligament. Damage to the nasolacrimal drainage apparatus, cerebrospinal fluid rhinorrhea and frontal sinusitis can occur. Twelve cases of naso-orbital trauma have been reviewed. There is a high incidence of associated injury to adjacent structures. Medial canthal ligament separation was missed acutely in a number of cases leading to the necessity of delayed repair. Important diagnostic and therapeutic points are stressed in the acute and delayed management, particularly medial canthal ligament separation. A wire to intranasal button technique for the delayed repair of traumatic telecanthus is presented.

Topics: Adolescent; Adult; Brain Injuries; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Eye Injuries; Fractures, Bone; Humans; Ligaments; Nose; Orbit; Surgery, Plastic

The site of cerebrospinal fluid leaks from the nose can be localized by means of radioactive substances. The technical aspects are important for success.

Topics: Cerebrospinal Fluid Rhinorrhea; Gossypium; Humans; Nose; Radioisotopes; Ytterbium

Our experiences in managing 17 patients with nasofrontal-ethmoidal injuries is reviewed. The treatment of frontal injuries, cerebrospinal fluid leaks, and pseudohypertelorism is discussed.

Topics: Adolescent; Adult; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Ethmoid Bone; Female; Frontal Bone; Humans; Hypertelorism; Male; Middle Aged; Nose

Traumatic cerebrospinal fluid fistulas in children are not rare as described by Harwood-Nash and Caldicott, North, and Simpson. Those involving the sphenoid bone apparently are rare, particularly in early childhood.

Topics: Cerebrospinal Fluid Rhinorrhea; Child, Preschool; Female; Humans; Meningitis; Myelography; Nasopharynx; Nose; Sphenoid Bone; Trigeminal Nerve

Topics: Brain Diseases; Cerebrospinal Fluid Rhinorrhea; Ethmoid Bone; Female; Fistula; Humans; Hydrocephalus; Intracranial Pressure; Male; Nasal Cavity; Nose; Skull

Topics: Cerebrospinal Fluid Rhinorrhea; Cryosurgery; Epistaxis; Fractures, Bone; Histiocytoma, Benign Fibrous; Humans; Mucous Membrane; Nasal Polyps; Nasopharyngeal Neoplasms; Nose; Nose Deformities, Acquired; Nose Diseases; Nose Neoplasms; Rhinitis; Rhinoplasty; Rosacea; Skin Neoplasms

Topics: Accidents, Traffic; Adolescent; Adult; Cerebrospinal Fluid Rhinorrhea; Child; Emergencies; Facial Injuries; Female; Follow-Up Studies; Fracture Fixation, Internal; Frontal Sinus; Humans; Lacrimal Apparatus; Male; Maxillary Fractures; Middle Aged; Nasal Septum; Nose; Orbit; Postoperative Complications; Radiography; Skull Fractures

Topics: Airway Obstruction; Cerebrospinal Fluid Rhinorrhea; Edema; Facial Injuries; Fracture Fixation; Fracture Fixation, Internal; Fractures, Bone; Humans; Maxillary Sinus; Methods; Nose; Orbit; Zygomatic Fractures

Topics: Age Factors; Anti-Bacterial Agents; Blood Pressure; Brain Diseases; Brain Edema; Central Venous Pressure; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Craniofacial Dysostosis; Emphysema; Face; Humans; Infant; Infant, Newborn; Intracranial Pressure; Nose; Orbit; Osteotomy; Postoperative Complications; Respiratory Insufficiency; Skin Transplantation; Skull; Surgery, Plastic; Transplantation, Autologous; Urinary Catheterization

Topics: Cerebrospinal Fluid Rhinorrhea; Ethmoid Bone; Ethmoid Sinus; Humans; Methods; Nose; Transplantation, Autologous

Topics: Cerebrospinal Fluid Rhinorrhea; Ear; Ear, Middle; Facial Injuries; Humans; Larynx; Maxillary Fractures; Nose; Paranasal Sinuses; Skull Fractures

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Cerebrovascular Circulation; Craniotomy; Humans; Hydrocephalus; Intracranial Pressure; Male; Middle Aged; Nose; Pneumocephalus; Pressure; Radiography; Vasomotor System

Topics: Bone Plates; Cerebrospinal Fluid Rhinorrhea; Craniofacial Dysostosis; Epistaxis; Ethmoid Bone; Face; Facial Bones; Facial Injuries; Fracture Fixation; Frontal Bone; Frontal Sinus; Humans; Lead; Nose; Radiography; Skull Fractures

Topics: Cerebrospinal Fluid Rhinorrhea; Child; Humans; Male; Methods; Nose; Radionuclide Imaging; Time Factors

Topics: Cerebral Ventricles; Cerebrospinal Fluid; Cerebrospinal Fluid Rhinorrhea; Humans; Nose

Topics: Brain Diseases; Cerebral Ventricle Neoplasms; Cerebrospinal Fluid Rhinorrhea; Fistula; Humans; Hydrocephalus; Intracranial Pressure; Nose; Papilloma; Pneumoencephalography; Subarachnoid Space

Topics: Adult; Atrophy; Cerebral Ventriculography; Cerebrospinal Fluid; Cerebrospinal Fluid Rhinorrhea; Child; Coloring Agents; Female; Fistula; Follow-Up Studies; Humans; Hydrocephalus; Male; Middle Aged; Nose; Nose Neoplasms; Osteomyelitis; Postoperative Complications; Pressure; Radionuclide Imaging; Serum Albumin, Radio-Iodinated; Skull; Sphenoid Sinus

Topics: Adolescent; Adult; Cerebrospinal Fluid Rhinorrhea; Female; Frontal Bone; Humans; Male; Middle Aged; Nose; Skull Fractures

Topics: Adult; Cerebrospinal Fluid Rhinorrhea; Female; Humans; Male; Meningitis; Nose; Skull Fractures

Topics: Cerebrospinal Fluid Rhinorrhea; Congenital Abnormalities; Craniocerebral Trauma; Diagnosis; Ethmoid Bone; Humans; Meningeal Neoplasms; Meningioma; Meningitis; Nose; Pneumocephalus; Radiography; Skull Fractures; Wounds, Gunshot

Topics: Cerebral Ventriculography; Cerebrospinal Fluid Rhinorrhea; Fistula; Follow-Up Studies; Hematoma; Hematoma, Subdural; Humans; Nose; Pneumocephalus; Radiography; Skull Fractures; Surgical Procedures, Operative

Topics: Adolescent; Cerebrospinal Fluid Rhinorrhea; Craniocerebral Trauma; Humans; Meningitis; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Humans; Meningitis; Nose; Skull; Synostosis

Topics: Cerebrospinal Fluid Rhinorrhea; Humans; Nose

Topics: Cerebrospinal Fluid; Cerebrospinal Fluid Rhinorrhea; Humans; Neoplasms; Nose; Pituitary Gland

Topics: Cerebrospinal Fluid; Cerebrospinal Fluid Rhinorrhea; Humans; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Craniocerebral Trauma; Humans; Nasopharyngitis; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Ethmoid Bone; Ethmoid Sinus; Frontal Sinus; Humans; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Humans; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Humans; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Eustachian Tube; Head; Humans; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Humans; Nose

Topics: Cerebrospinal Fluid Rhinorrhea; Humans; Nose; Otolaryngology; United States