Objective To investigate the effectiveness of transnasal endoscopic treatment of traumatic refractory cerebrospinal fluid rhinorrhea.
Methods Retrospective study of the treatment and efficacy of 27 cases of cerebrospinal fluid rhinorrhea treated surgically in our department since September 2001 to January 2008.
Results Among the 27 patients, 18 cases were cranially repaired, and 4 cases were recurred in 1~3 years of follow-up, with an efficiency of 78%. 9 cases were treated by transnasal endoscopy, with no recurrence in 6 months~2 years of follow-up, with an efficiency of 100% and no significant complications.
Conclusion Transnasal endoscopic surgery to repair the leak under direct vision and avoid craniotomy is an ideal surgical method for the treatment of traumatic cerebrospinal fluid nasal leak. Pang Qijun, Department of Neurosurgery, Cangzhou Central Hospital
Materials and methods
I. General information
During the period from September 2001 to June 2008, 27 patients with traumatic cerebrospinal fluid nasal leakage were treated surgically in our department, including 20 males and 7 females, aged 3 to 68 years old, with an average age of 38.3 years. The duration of the disease ranged from 4h to 30d.
II. Preoperative diagnosis
The preoperative diagnosis of cerebrospinal fluid rhinorrhea was mainly based on medical history and clinical manifestations. 27 cases all had a clear history of trauma and obvious clinical manifestations. CT examination of sinuses was performed in 20 cases, and preoperative nasal endoscopy was performed in 9 cases.
Treatment method
All 25 patients in this group were absolutely bedridden for 4 weeks before surgery, avoiding sneezing, preventing stool secretion, using laxatives as appropriate, using systemic antibiotics that can easily penetrate the blood-brain barrier, etc. After treatment was ineffective, 5 of them applied mannitol, 3 of them had lumbar puncture tubes to continuously lower cranial pressure, and 2 other patients were admitted to the hospital for surgery directly because of their long medical history, 1 case was 28d and 1 case was 30d.
1, craniotomy repair 18 cases: 5 cases of unilateral craniotomy, 13 cases of bilateral craniotomy. All of them took a coronal incision, frontal lobe craniotomy, turned the flap to the face side, and separated outside the dura after entering the cranium to reveal the base of the anterior cranial fossa in order to explore the leak. Leakage: saddle base of pterygoid sinus in 3 cases, sieve plate in 9 cases, frontal plate in 2 cases, anterior sieve and frontal plate in 4 cases. Repair materials: tipped temporalis flap in 2 cases, broad muscle fascia plus muscle pulp in 6 cases, direct suturing of dural leaks plus biologic adhesive in 10 cases.
2. Since February 2006, our department has been gradually carrying out nasal endoscopic repair in 9 cases, all of which were examined by nasal endoscopy before surgery. The lateral broad fascia of the thigh and the muscle tissue beneath it were taken as a backup. During surgery, the fistula holes were lined up in strict order of anterior nasal roof → posterior roof → pterygopalatine septal fossa → middle nasal tract → eustachian tube opening to prevent misdiagnosis [1]. In this group, the cerebrospinal fluid nasal leak was located in the sieve plate in 5 cases, the sieve apex in 2 cases, and the pterygoid sinus in 2 cases. The granulation tissue around the leak was removed by nasal endoscopy, the leak was moderately enlarged, and mashed muscle was laid over the leak with broad fascia. The surface of the fascia was then covered with gelatin sponge and iodoform gauze.
Results
The follow-up period was 6 months to 3 years. There were 18 cases of craniotomy, 4 cases of recurrence, the efficiency was 78%, among which 1 case gave up the treatment, and the remaining 3 cases were repaired successfully after reoperation. 6 cases were combined with complications, including 3 cases of olfactory loss, 2 cases of intracranial infection and 1 case of pulmonary infection. 9 cases of nasal endoscopic repair were all successful, the efficiency was 100%, except for 1 case complaining of mild nasal dryness, there were no obvious complications.
Discussion
The literature reports that more than 85% of patients with cerebrospinal fluid rhinorrhea are cured by palliative treatment [2], so conservative treatment should be given first in general, especially for trauma, and some scholars believe that surgery should be considered for cerebrospinal fluid rhinorrhea lasting more than 2 weeks without a tendency to heal spontaneously and for recurrent rhinorrhea. However, in cases of recurrent recurrence after conservative treatment or severe meningeal brain expansion complicated by head and facial trauma, surgery should be performed as soon as possible. In the past, most patients with traumatic refractory cerebrospinal fluid rhinorrhea admitted to neurosurgery were treated by intracranial pathway repair, and according to Marshall et al [3], the success rate was 50%-73%, which was similar to the results of our group (78%). Since 1981, when Wigand, a German rhinologist, first successfully reported transnasal endoscopic repair of cerebrospinal fluid rhinorrhea, it has been widely used in cerebrospinal fluid rhinorrhea repair surgery because it has greatly simplified the procedure, shortened the operative time, improved the accuracy and success rate, and reduced postoperative complications. All nine cases in this group were repaired successfully in a single visit, with no complications or recurrence at a postoperative follow-up of 6 months to 2 years. The advantages of transnasal endoscopic repair of cerebrospinal fluid nasal leak are in accordance with the principle of minimally invasive neurosurgery [4], which include.
(i) the fistula can be repaired with minimal damage by direct visualization of the fistula hole;
(ii) Easy access, minimal damage, and no facial scars;
③Fast recovery, less cost, nasal gauze extraction on the 4th to 7th postoperative day, the patient’s conscious symptoms disappear, and the average hospital stay is 11d;
④It can avoid intracranial injury and defect of brain tissue
⑤ Its success rate of one time repair of cerebrospinal fluid nasal leak is significantly higher than that of intracranial or nasal external route methods;
⑥The structure and function of the organ are preserved to the maximum extent. The key to transnasal endoscopic treatment of traumatic cerebrospinal fluid nasal leak is whether the leak can be found successfully [5], and preoperative CT scan or 3D CT reconstruction of the skull base nasal endoscopy to determine the location of cerebrospinal fluid nasal leak is an important aspect [6], and intraoperative tracing of the source of clear fluid with an aspirator, scraping of the diseased tissue, and detailed examination. If necessary, lumbar puncture is feasible to inject a small amount of fluorescein contrast into the subarachnoid space, and then the location of the leak is determined via nasal endoscopy. The material used for repair is usually autologous broad fascia, mashed muscle, and mucosa of the middle or inferior turbinate with bone stripped away from the periosteum. In our group, autologous broad fascia was used in all cases with good results. Although nasal endoscopic repair of traumatic refractory cerebrospinal fluid rhinorrhea has many advantages, it also has some limitations, such as the posterior wall of the frontal sinus, lateral pterygoid sinus, pterygoid process and other parts of the fistula are difficult to see.
In summary, as long as the principles of treatment are mastered, direct visual repair of the leak via nasal endoscopy, avoiding craniotomy, is the ideal surgical method for the treatment of traumatic refractory cerebrospinal fluid rhinorrhea. Currently, otolaryngologists have been working tirelessly on this research, and it is very important for neurosurgeons to master this technique as soon as possible.