1/24. Otogenic cerebrospinal fluid rhinorrhea: a new technique for closure of cerebrospinal fluid leak.OBJECTIVE: To describe a new technique for control of cerebrospinal fluid (CSF) rhinorrhea and to review alternative approaches. STUDY DESIGN: Five cases and literature review. SETTING: Tertiary referral center. patients: Five case study patients. INTERVENTION: Surgical. MAIN OUTCOME MEASURE: Control of CSF rhinorrhea. RESULTS: CSF rhinorrhea can be controlled through eustachian tube ligation in the nasopharynx, distal to all known pathways through which CSF leaks may occur from the temporal bone into the eustachian tube. CONCLUSION: Transoral eustachian tube ligation appears to be a safe and effective alternative to other techniques for controlling CSF rhinorrhea and should be included in the otologist's repertoire.- - - - - - - - - - ranking = 1keywords = closure (Clic here for more details about this article) |
2/24. Successful closure of recurrent traumatic csf rhinorrhea using the free rectus abdominis muscle flap.BACKGROUND: We present two patients in whom a free rectus abdominis muscle flap was used to close recurrent traumatic CSF rhinorrhea. CASE DESCRIPTION: CT scan of both patients showed frontal lobe atrophy and porencephaly after contusional hematoma. In the first patient, because the site of CSF leakage was not identified and the patient underwent three unsuccessful attempts to close the fistula using the fascia lata, we treated the patient by unifying all paranasal sinuses and by filling them with a free rectus abdominis muscle flap. In the second patient, CSF rhinorrhea recurred 6 years after closure of the fistula using the fascia lata. The patient underwent separation of a porencephalic cyst from the paranasal sinus and a free muscle flap was placed extradurally, because the CSF pulse pressure in the enlarged left anterior horn eroded the previously repaired fascia lata, resulting in the recurrence of CSF leakage. CONCLUSION: Although duraplasty is the primary procedure for repairing dural fistulas, the vascularized free muscle flap is an alternative method when the location of the fistula is not identified or the patient with recurrent CSF rhinorrhea has severe frontal lobe atrophy and porencephaly.- - - - - - - - - - ranking = 1.25keywords = closure (Clic here for more details about this article) |
3/24. Delayed cerebrospinal fluid rhinorrhea seven months after transsphenoidal surgery for pituitary adenoma--case report.A 51-year-old female had undergone transsphenoidal surgery for pituitary adenoma producing growth hormone. Cerebrospinal fluid (CSF) leakage occurred during surgery. The sella turcica and sphenoid sinus were packed with abdominal fat and fibrin glue, buttressing the closure with a fragment of sphenoid bone. No CSF rhinorrhea occurred postoperatively. Severe meningitis developed 7 months later. CSF rhinorrhea occurred 10 days after readmission. Exploration through the transsphenoidal approach identified a small hole at the floor of the sella and CSF leaking into the sphenoid sinus through the hole. The CSF leakage stopped after the second surgery. Delayed CSF rhinorrhea without bromocriptine administration is very rare. The cause of delayed CSF rhinorrhea remains unclear. CSF rhinorrhea should be suspected if meningitis develops even months after transsphenoidal surgery.- - - - - - - - - - ranking = 0.25keywords = closure (Clic here for more details about this article) |
4/24. Subtotal petrosectomy in the treatment of cerebrospinal fluid fistulae of the lateral skull base.Cerebrospinal fluid (CSF) fistulae almost invariably lead to meningitis, even in the absence of other clinically obvious sequelae of the fistula such as a CSF fluid leak. The only effective means of reducing the risk of meningitis is surgical closure of the fistula. If surgery is to be recommended to patients with CSF fistulae even if they are currently asymptomatic, the morbidity of the procedure must be a principal determinant of the chosen technique. Recovery after the extracranial approach to a CSF fistula is much more rapid than after an intracranial procedure. The extracranial route is also free of the long-term risk of epilepsy which accompanies a craniotomy. The principal disadvantage of the lateral extracranial approach, failure of treatment, has been largely eliminated following studies into the obliteration of simple bony cavities using free adipose grafts. This paper describes our use of the extracranial approach to closure of CSF fistulae of the lateral skull base.- - - - - - - - - - ranking = 0.5keywords = closure (Clic here for more details about this article) |
5/24. Closure of recurrent frontal skull base defects with vascularized flaps -- a technical case report.Techniques for vascularized reconstruction of the anterior cranial fossa floor defects causing recurrent cerebrospinal fluid fistula are discussed in this report. The closure employs the use of local random- or axial-pattern vascularized flaps in simple cases. In complicated cases (for instance, status after repeated exploration) the tissue of the cranial base is severely compromised and shows low potential for healing. Non-vascularized grafts only add avital scars to the already present ones leading to recurrent fistulas. Free vascularized flaps show more mechanical strength and less scar contraction, resistance to infections and survive better in a compromised surrounding, thus leading to long term sealing in such cases. The technical issues of vascularized closure of defects of the frontal skull base are discussed in this report.- - - - - - - - - - ranking = 0.5keywords = closure (Clic here for more details about this article) |
6/24. Sphenoethmoid cerebrospinal fluid leak repair with hydroxyapatite cement.Despite advances in neurological, reconstructive, and endoscopic sinus surgery, sphenoethmoid cerebrospinal fluid (CSF) fistulae continually pose difficult management problems. Standard surgical techniques for fistulae closure succeed approximately 78% to 90% of the time. To improve this success rate, hydroxyapatite cement (HAC), a food and Drug Administration-approved substance for cranial defect repair, was applied to this problem in a clinical setting. Twenty-one patients with spontaneous, posttraumatic, or postoperative CSF leaks of the sphenoid sinus, cribriform plate, or ethmoid region were treated with HAC. Study participants were prospectively accrued at 5 tertiary care medical centers in the eastern united states. The CSF leaks of all 21 patients treated with HAC were successfully sealed by its initial application. The sites of CSF leakage included the nasal cavity (n = 2) and sphenoid sinus (n = 19). Fifteen of the patients had previously undergone a failed repair by standard methods. There have been no recurrent CSF leaks with a maximum follow-up of 72 months, and an average follow-up of 36 months. All patients have survived to date. The only HAC-related morbidity was the extrusion of the HAC when placed in the nasal cavity. Hydroxyapatite cement is an effective method of repair for postoperative, posttraumatic, and spontaneous sphenoid CSF leaks. The efficacy of HAC in sealing the CSF leak was unaffected by previous attempts at leak closure by standard methods or by its origin. Hydroxyapatite cement should not be applied transnasally for the treatment of an ethmoid region fistula owing to its high probability of extrusion. Correct patient selection and technical familiarity with HAC are necessary for successful application.- - - - - - - - - - ranking = 0.5keywords = closure (Clic here for more details about this article) |
7/24. Complications of hydroxyapatite use for transnasal closure of cerebrospinal fluid leaks.BACKGROUND: Hydroxyapatite cement (HAC) was first introduced in the 1980s as a new method for bone replacement. However, it has not been recommended for use in areas exposed to air. Despite this, surgeries have been performed using HAC to close nasal/sinus cerebrospinal fluid (CSF) leaks or in the treatment of encephaloceles. methods: This study retrospectively documented four patients in whom HAC was used for closure of ethmoid and sphenoid sinus CSF leaks. RESULTS: This study showed that exposed hydroxyapatite could be extremely problematic resulting in scarring, chronic granulation, infection, and prolonged healing. Oftentimes, revision surgery was necessary to help control the reaction to hydroxyapatite. CONCLUSION: Because of the frequent complications occurring with use of hydroxyapatite in the paranasal sinuses, its use should be limited to selected individuals in whom difficulty in achieving closure of the CFS leak could be anticipated and in whom adequate tissue coverage could be provided.- - - - - - - - - - ranking = 1.5keywords = closure (Clic here for more details about this article) |
8/24. Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery.OBJECTIVE: The most common postoperative complication of the transsphenoidal approach is cerebrospinal fluid (CSF) rhinorrhea. If the dura is widely opened beyond the sellar floor and massive intraoperative CSF leakage is encountered, then the conventional packing method, in which the sella turcica is filled with pieces of fat or muscle, demonstrates a relatively high incidence of CSF rhinorrhea. For more reliable prevention of postoperative CSF leakage, we developed a method for watertight closure of large dural defects. methods: For 34 consecutive patients with suprasellar tumors, we performed tumor resection via an extended transsphenoidal approach, in which the surgical window in the sellar floor was extended to the planum sphenoidale to expose the suprasellar cistern. The patients were retrospectively divided into three groups according to the dural defect closure technique used. Group I consisted of the first two patients, whose large dural openings were closed with a conventional fat-packing method. Group II consisted of the next 10 patients, whose large dural defects were patched with fascia and sutured with 5-0 nylon, in a watertight manner. Group III consisted of the last 22 patients, who underwent watertight dural closure with a new knot-tying technique and a double-layer patch graft, which generously covered the dural defect of the cranial base with subdural placement. In Group III, intracranial CSF compressed the patch graft against the cranial base and sealed the gap between the patch graft and the cranial base in a watertight manner. The double-layer patch graft was composed of autologous fascial membrane and a commercially available, expanded polytetrafluoroethylene dural substitute. RESULTS: Postoperative CSF leakage was noted for 50% of the patients in Group I, 30% of the patients in Group II, and 9% of the patients in Group III. The time required for dural closure for Group III was approximately 50% shorter than that required for Group II (45.9 /- 12.4 min versus 93.5 /- 19.1 min, P < 0.001). CONCLUSION: The subdural double-layer patch graft technique is simple and reliable for the prevention of CSF rhinorrhea after transsphenoidal surgery associated with a widely opened dura.- - - - - - - - - - ranking = 2keywords = closure (Clic here for more details about this article) |
9/24. Spontaneous cerebrospinal fluid rhinorrhea.The diagnosis of CSF rhinorrhea requires the performance of a thorough history and physical examination. Often no objective findings can be found and further evaluation will be required. In our experience, metrizamide CT cisternography yields the most information for localization of the fistula. When indicated, patients can be protected against meningitis by using prophylactic antibiotics for 4-6 weeks to allow a fistula to close spontaneously. If the fistula fails to close during this time, surgical closure with dural or muscle graft with or without waxing of the bone is the treatment of choice.- - - - - - - - - - ranking = 0.25keywords = closure (Clic here for more details about this article) |
10/24. Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control.The surgical management of cerebrospinal fluid (CSF) rhinorrhea has changed after the introduction of functional endoscopic sinus surgery.The following three cases illustrate the repair of CSF leaks with the use of rigid endoscope. Two patients had the diagnosis and the site confirmed after intrathecal fluoresceine saline injection. The obliteration of the CSF was achieved with fat free, mucoperichondrial or mucoperiostal free grafts taken from middle or inferior turbinate and kept in place by fibrin glue. Primary closure was achieved in all patients. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, effective and is a valid alternative to the cranial approach.- - - - - - - - - - ranking = 0.25keywords = closure (Clic here for more details about this article) |
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