| Abstract: |
CSF rhinorrhea results from a breakdown of the dura and supporting structures of the skull base, resulting in connection between the subarachnoid space and the nose. It occurs commonly following head trauma, surgery, tumors and other destructive lesions, or spontaneous with high ICP. Sites of lesions include the cribiform plate, ethmoid, sphenoid and frontal sinuses. These fistulas must be repaired to avoid imminent life-threatening complications like ascending meningitis and pneumocephalus. The diagnosis and management of CSF rhinorrhea continues to be one of the most challenging and difficult issues facing otolaryngologists and neurosurgeons. Confirmation of the nature of the leak, identification of its etiology and localizing the site of the leak allows the surgeon to choose the best management strategy, surgical approach and closure technique. Management of cerebrospinal fluid leak has undergone significant evolution throughout the past century. The relatively high morbidity and low success rate of intracranial approach have led scientists to search for other methods. Extracranial approaches have been developed sience 1948 but have not gained acceptance. Endonasal endoscopic technique; since the first reports by Wigand and Stankiewicz in 1981, have been widely used. More recently, several reports have been published that describe the different endoscopic technique and variable tissue for management.Objectives: The aim of this work is to evaluate the multilayer endoscopic closure technique in cases of CSF rhinorrhea of anterior and middle cranial fossa.Patients and methods: This study was done at Zagazig University Hospitals on 25 patients suffered from CSF rhinorrhea. All patients underwent endoscopic repair of CSF rhinorrhea with multilayer technique in the period from March 2008 to July 2011. Every patient had been evaluated by full history taking, thorough clinical examination, cytological and chemical analysis of the CSF, CT scan with metrizamide, MRI in selective cases and preoperative intrathecal injection of fluorescein.Results: In this study, the most common cause of CSF rhinorrhea was accidental trauma (44%) followed by iatrogenic trauma in (28%), then spontaneous in (28%) of the cases. The most common site of CSF leak in this study was in the cribriform area (40%) where the bone is thinner and dura adherent to this bone is stronger, followed by the anterior ethmoidal area. Multilayer technique was performed in all cases of CSF rhinorrhea. This technique has several advantages over other techniques as it provides both structural support from the bone or cartilage and watertight closure from fascia or soft gelfoam, it reconstructs both the bone and the soft tissue aspect of the defect, addressing the short-term goal of CSF leak cessation and the long-term goals of preventing encephalocele, CSF recurrence or ascending meningitis. In this study, no patients developed any major complications such as meningitis, pneumocephalus, vision problem or death. This minimally invasive technique in well-tolerated by the patient because of short period of hospitalization, rapid recovery to normal activities, minimal morbidity, decreased incidence of anosmia or neurological defects from prolonged brain retraction that occurs during intracranial operation, and absence of external fascial incisions.Conclusion: Endoscopic repair of CSF rhinorrhea provides a better field of vision with enhanced illumination, magnified angle of visualization and accurate positioning of the graft.
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