The treatment of CSF (cerebrospinal fluid) nasal leakage includes: conservative treatment, CSF shunt and surgical repair. Some scholars believe that the CSF shunt approach has poor long-term efficacy and risks of inducing infection and pneumocephalus [1]; it is rarely used alone, but it can be used as one of the adjuvant treatments. In the case study of this paper, except for the method of CSF shunt, other treatment methods were applied, and the advantages and disadvantages of various methods, the choice of treatment plan, and some of its key issues are analyzed below. Duckert believes that 26% of traumatic CSF nasal leaks can be conservatively cured on their own. Conservative treatment should also be implemented throughout the treatment of CSF rhinorrhea. The so-called conservative treatment means that the patient is in a semi-recumbent position, avoiding forceful nasal blowing, sneezing and other actions that increase abdominal pressure, giving antibiotics, prohibiting hormones; using mannitol to lower cranial pressure as appropriate; or repeated lumbar puncture to lower cranial pressure and other measures. How to master the course of conservative treatment, or choose the timing of surgical repair is the most important concern of clinicians. Relevant data show that the healing time of conservative treatment is 1-56 days, with an average of 16 days. Some literature suggests that post-traumatic CSF nasal leak should be surgically repaired after 6 weeks of conservative treatment without improvement, and in cases where x-ray shows enlarged pneumocephalon or persistent meningitis. It has also been suggested that CSF nasal leak lasting more than 10 days increases the chance of secondary intracranial infection; therefore, surgical repair should be considered for CSF nasal leak lasting more than 2 weeks without a tendency to heal spontaneously, or for recurrent leaks. We believe that the duration of conservative treatment should be determined according to the specific condition, usually 2 to 4 weeks, and if there is no sign of reduction or increase in the amount of leakage during this period, or if it is accompanied by recurrent intracranial infections and no reduction in intracranial pneumonia, surgical repair should be performed as soon as possible. Individual cases can be treated conservatively for 6-8 weeks for other reasons. In contrast, spontaneous CSF nasal leak should be operated as soon as possible. The choice of surgical repair methods for CSF nasal leak There are many methods for surgical repair of CSF nasal leak, including intracranial and extracranial methods, and the extracranial method is divided into two types: intranasal and extracranial approaches. Many scholars have previously studied the indications for different methods and made guiding recommendations. However, in recent years, with the development of imaging, digital technology and minimally invasive surgical techniques, the traditional concept of surgical treatment of CSF nasal leaks has changed. 1. Craniotomy repair, the traditional surgical treatment of CSF nasal leak is craniotomy repair by neurosurgery, which has the advantage of repairing the leak under direct vision while dealing with intracranial lesions, especially when the leak is large or the bone defect at the skull base is large. The disadvantages are large trauma, certain risk, long operation and hospital stay, heavy reaction, often affecting the sense of smell, some reports that it is not easy to find the leaky hole intraoperatively, and the failure rate of the operation is about 27%. Therefore, we believe that the indications for this surgery are: CSF nasal leak with intracranial occupying lesions (such as intracranial hematoma, skull base communication tumor, etc.), or the presence of other indications for intracranial exploration (such as open craniofacial injury, etc.). Since Dohlman (1948) first reported the treatment of CSF rhinorrhea by the external nasal approach, it has pioneered the treatment of CSF rhinorrhea by otorhinolaryngology and head and neck surgery. The external nasal approach has shown its advantages in the management of CSF rhinorrhea of the frontal sinus. The disadvantage of this procedure is that it affects the frontal surface aesthetics, and when repairing CSF rhinorrhea in the septoparietal or pterygoid sinuses, the middle turbinate is often destroyed, which affects the function of the nose. However, with the continuous development of nasal surgery techniques, the external nasal approach has been replaced by the internal nasal approach, especially the nasal endoscopic surgery technique. Since 1952, when Hirsch first used the endonasal approach to repair CSF nasal leaks with the septal mucosa, the operation under the microscope is a major advancement of this procedure. The advantage of this procedure is that the operative field is clear and magnified, and it can be operated with both hands to facilitate the operation. However, the operative field is narrow and limited by linear observation, and there are blind areas in the field of view, such as the lateral wall of the pterygoid sinus and the frontal saphenous fossa. We believe that this procedure is suitable for CSF nasal leaks where the leak is located in the posterior sieve roof, sieve plate and parietal wall of the pterygoid sinus, and the site of the leak is relatively clear. Since Papay (1989) reported the use of nasal endoscopy to repair CSF nasal leaks, the application of this technique has been widely developed and gradually matured, showing its great advantages in the surgical treatment of CSF nasal leaks. The advantages of this technique are: (1) the preoperative examination and intraoperative determination of the site of the leak are more accurate. ②
Satisfactory and clear exposure of the operative field; almost no blind area from the opening of the nasofrontal canal to the pterygoid sinus area. ③ Small trauma, quick recovery and short hospitalization time for patients. ④ In most cases, the middle turbinate can be preserved, and the impact on nasal function is small. Its shortcomings.
The frontal sinus exposure is limited; it is a one-handed operation; and requires high technical requirements for nasal endoscopy application. In conclusion, nasal endoscopic repair is suitable for all types of CSF nasal leaks, but CSF nasal leaks with intracranial lesions require neurosurgical assistance or craniotomy; if the CSF nasal leak occurs in the frontal sinus lamina and the nasal endoscope cannot completely expose the area, then an external nasal approach is required for repair. Repair materials The repair materials can be divided into two main categories, one is with the tip: such as temporal muscle flap with the tip, temporal muscle fascial flap, capillary key membrane, which are mostly used for repair in craniotomy, mucosal flap with the tip of the nasal septum or mucosal flap of the middle turbinate, etc.; the second is free tissue, such as muscle pulp, broad fascia, nasal mucosa, fat and bone fragments, etc.; there are also biological materials such as medical gum (including liquid and block The other biomaterials are medical gels (both liquid and block). Hegazy
HM
(2000) concluded in a Meta-analysis that there was no difference in the results of applying tipped tissue flaps compared to free tissue, which has been used in the majority of cases in recent years (91%). As for the placement of the repair material on the intracranial or cranial base side of the leak, Hegazy
HM believes that this does not affect the healing result, and it is easy to affect the sense of smell when it is placed on the skull base side, and only 12% of cases are placed on the inner side of the skull. Fourth, reoperation There are reports of 27% failure in one operation of craniotomy and 10% failure in reoperation.
HM reported 289 cases of CSF nasal leak repaired by nasal endoscopy, the success rate of the first time was 90%, the second time accounted for 52%, and finally 97% of the cure rate. The reasons for reoperation were analyzed as follows: ①
Postoperative complications of meningitis, which affected the wound healing. ② The first surgery failed to fully expose the leak, which should have included the bone defect and all edges of the meningeal leak and scratched. ③ More than one leak was missed. ④
Intraoperative intracranial pressure was too high; the repair material was not uniform or did not fit tightly with the leak; or postoperative measures were inappropriate, etc. cannot be excluded. In summary, we have good reasons to believe that nasal endoscopic CSF nasal leak repair is the preferred surgical treatment for CSF nasal leak, and other repair methods can be appropriately selected according to the needs of the condition, the conditions of the hospital and the experience of the surgeon.