MANAGEMENT OF CSF RHINORRHEA, MENIGIOCELES, Steven D. Schaefer, MD, FACS Professor and Chair Department of Otolaryngology New York Eye and Ear Infirmary New York Medical College Anatomy and Physiology of Cerebrospinal Fluid Etiology of CSF Rhinorrhea Iatrogenic Traumatic Spontaneous Evaluation of CSF Rhinorrhea Physical Examination, β-2-transferrinase CT, Coronal CT, CT Cisternogram MRI Flourescein Treatment of CSF Rhinorrhea Endoscopic Grafts v Flaps v Bone or Cartilage Treatment of Meningoceles and Encephaloceles
Anatomy and Physiology Cerebrospinal Fluid Production 350-500 ml/day Choroid plexus in lateral, 3 rd and 4 th ventricles Absorption Absorbed by arachnoid villi Opening pressure of arachnoid villi is 1.5-7cmH 2 O Pressure 5-15 cm H 2 O assumes an intact intrathecal space Etiology of CSF Rhinorrhea Iatrogenic Neurosurgical Injuries Sinus Surgery Injuries Head dt Trauma Tumors Congenital Spontaneous (increased ICP)
Iatrogenic Etiology of CSF Rhinorrhea #2 Neurosurgical Injuries Sinus Surgery Injuries Etiology #1 Incidence Complications Head Trauma Tumors Congenital Spontaneous (increased ICP) b>2a a olfactory fila b #3 after Meyers 1998 #4 Iatrogenic Neurosurgical Injuries Etiology of CSF Rhinorrhea Sinus Surgery Injuries Etiology Incidence 1987, 1.1%; 2004, 0.1%; 2006, 0.04-6% Complications meningitis, 0-36%, 1997, 1998, 2000, pnuemocephalus, intracranial hemorrhage, death Head Trauma Tumors Congenital Spontaneous (increased ICP)
Iatrogenic Neurosurgical Injuries Sinus Surgery Injuries Head Trauma Tumors Congenital Spontaneous Etiology of CSF Rhinorrhea Obese, female>>male, ICP vs. skull base defect, +/- require shunting Lloyd, Radiology 2008 Evaluation History, Acute vs. Chronic Fistula Physical Examination Complete Head and Neck Exam Provocative Exam β-2-transferrinase2 Imaging Coronal CT MRI Contrast Cisternogram Intrathecal Fluorescein
Evaluation History, Acute vs. Chronic Fistula Physical Examination Complete Head and Neck Exam Provocative exam β-2-transferrinase 2 Imaging Coronal CT MRI Contrast Cisternogram Intrathecal Fluorescein Lloyd, Radiology 2008 c. Sagittal T1MRI d. Coronal T1 MRI postcontrast e. Coronal >T2 MRI cisternogram Evaluation History, Acute vs. Chronic Fistula Physical Examination Complete Head and Neck Exam Provocative exam β-2-transferrinase Imaging Coronal CT MRI Contrast Cisternogram Intrathecal Fluorescein 8/00 58 y/o obese female with spontaneous CSF rhinorrhea, s/p 3 attempted repairs of fistula into sphenoid sinus and meningitis 1/09
ACUTE vs CHRONIC CSF RHINORRHEA MANAGEMENT Acute CSF Rhinorrhea Intraoperative Fistula Immediate Repair using Intrathecal and Intranasal Fat or Graft, Tissue Glue, Absorbable Packing, +/- Lumbar Drainage Intraoperative ti antibiotics Postoperative Fistula Perioperative Lumbar drainage for Minimal Fistulas noted Postoperatively vs repair Postoperative CT Scan R/O Intracranial Injury 4/9/2009 CSF RHINORRHEA WITH ACUTE INTRACRANIAL INJURY Intracerebral Injury Beware of Indicators of Potential Intracranial Anomalies Immediate Neurosurgical Intraoperative Consult Anterior Cerebral Artery Injuries are Frequently Fatal, whereas Nonvascular Injuries Require Repair and Observation for Infection 4/9/2009 Prof W Hosemann
ACUTE vs CHRONIC CSF RHINORRHEA MANAGEMENT Chronic CSF Rhinorrheah Treat the Etiology Hx Meningitis? Selective Use of Fluorescein Repair using Graft, Tissue Glue, Absorbable Packing, Lumbar Drainage Intraoperative antibiotics Perioperative Lumbar Drainage 4/9/2009 Postoperative CT Scan Grafting Considerations Overlay, Underlay or Combined Grafting Grafting Material Mucous membrane, fascia, fat, bone, dermis, pericranium, myocardium skull base graft graft packing Intraoperative fluorescein Bath Plug -Wormald Graft Adhesion Packing - absorbable
Grafting Considerations Overlay, Underlay or Combined Grafting Grafting Material Mucous membrane, fascia, fat, bone, dermis, pericranium, flaps? (except posterior septal flap for sphenoid, sella and clivus, [ITF, MTF]) Bath plug - Wormald Graft Adhesion tissue glue Packing - absorbable Wormald overlay underlay
Grafting Considerations, Revisited Combined Grafting Grafting Material Best material fat or fascia lata>dermis> mucous membrane> pericranium> nasal flaps? No bone or cartilage Intrathecal graft must be water tight Packing - absorbable skull base graft bone
Flap Considerations, Revisited Intranasal Flaps Axial Posterior Septal Kassam, 2008 Inferior Turbinate Random Middle Turbinate Treatment of Meningoceles/Encephaloceles Meningioceles/Encephalocele i l l Treat the Etiology Meningitis precautions Remove (cauterize) Dura/Encephaloceles Selective Use of Fluorescein Repair using Graft, Tissue Glue, Absorbable Packing Lumbar Drainage Intraoperative antibiotics Perioperative Lumbar drainage 4/9/2009 Postoperative CT Scan
Encephaloceles Considerations, Revisited Cauterization Combined Grafting Grafting Material Fat intracranial, dermis intranasal No bone, no cartilage since 1980 s Packing - absorbable skull base brain Vascular injury Intrathecal Fluorescein sphenoid sinus 50 y/o female 10 yrs. s/p anterior cerebral artery aneurysm clipping
Intrathecal Fluorescein The spontaneous reporting number of adverse event caused by fluorescein sodium, fluorescein, fluorescite, and ak-fluor, US FDA data from 1968 to 2003 (number=187) Number of adverse eve ent 24 22 20 18 16 14 12 10 8 6 4 2 0 14 12 10 8 6 4 2 n=79 n=33 n=65 n=10 0 fluorescein fluo-sodium fluorescite ak-fluor 7 2 2 2 1 1 1 1970 1972 1974 9 1976 1978 1980 1982 1984 1986 6 4 6 3 13 8 20 19 1988 1990 1992 1994 1996 17 9 11 7 12 15 5 5 1998 2000 2002 Year from US Department of Commerce and FDA Keerl, Laryngoscope 2004 Intrathecal Fluorescein FLUORESCEIN CONCLUSIONS 1..No reported tedcomplication cato at<100mg intrathecal 2. Hypodense fluorescein sufficient for detecting intraoperative CSF rhinorrhea (ie, 0.5ml/100mg/ml diluted in 9.5ml = 5mg/ml, infuse 1-1.5ml) 1 3. Recommend 5-<50mg and legal considersation of informed consent
Anatomy and Physiology of Cerebrospinal Fluid Etiology of CSF Rhinorrhea Iatrogenic Traumatic Spontaneous Evaluation of CSF Rhinorrhea Physical Examination, β-2-transferrinase CT, Coronal CT, CT Cisternogram MRI Fluorescein Treatment of CSF Rhinorrhea Endoscopic Grafts vs Flaps vs Bone or Cartilage Schlosser, Laryngoscope 2004 Treatment of Meningoceles and Encephaloceles Last tthoughtsht 1. Lumbar Drain? 2. Antibiotics? 3. Positive Pressure Ventilation, Nose Blowing 4. Patient Selection 5. Results