Endoscopic management of frontal sinus CSF leaks

Gâta, Anda; Trombitas, Veronica Elena; Albu, Silviu

doi:10.1016/j.bjorl.2020.08.002

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Brazilian Journal of Otorhinolaryngology

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Sumário

ORIGINAL ARTICLE • Braz. j. otorhinolaryngol. 88 (4) • Jul-Aug 2022 • https://doi.org/10.1016/j.bjorl.2020.08.002 copy

Endoscopic management of frontal sinus CSF leaks

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition.

Objective:

To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach.

Methods:

A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined.

Results:

Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 – 41 months).

Conclusion:

Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Keywords
Cerebrospinal fluid leak; Frontal sinus; Endoscopic repair; Trephination; Skull base

Patient	Demography	Etiology	Defect location	Defect size (mm)	Surgical approach	Reconstruction technique	Follow-up (months)
1	M/31	Trauma	P.W.	20	Trep, IIB	Fat plug	41
2	M/42	Trauma	P.W.	40	IIB	Nasal mucosa	28
3	M/51	Trauma	P.W., Ethmoid	60	IIB	Fascia lata, cartilage	36
4	F/42	Spontan	Fr.	65	IIA	Nasal mucosa, cartilage	38
5	M/21	Trauma	P.W., Ethmoid	75	III	Fascia lata, cartilage	14
6	F/47	Trauma	P.W.	30	IIB	Nasal mucosa	10
7	F/32	Trauma	Fr., P.W.	70	IIB, trep	Fascia lata, cartilage fat graft	37
8	M/57	Trauma	P.W.	100	III	Fascia lata, cartilage	41
9	M/49	Spontan	P.W.	50	IIB	Fascia lata, cartilage, fat graft	34
10	M/67	Spontan	Fr.	35	IIA	Nasal mucosa	15
11	F/46	Spontan	P.W.	100	III	Fascia lata, cartilage, fat graft	24
12	F/40	Spontan	P.W., Ethmoid	100	III	Fascia lata, cartilage, fat graft	31
13	M/56	Trauma	P.W.	40	IIB	Nasal mucosa	26
14	M/27	Trauma	P.W.	50	IIB, trep	Fascia lata, fat graft	25
15	F/44	Trauma	Fr., P.W.	150	IIB	Fascia lata, cartilage	18
16	M/61	Trauma	P.W.	50	IIB, trep	Nasal mucosa, fat graft	17
17	M/39	Trauma	P.W.	40	IIB	Nasal mucosa	16
18	M/29	Trauma	P.W.,Ethmoid	50	IIB	Nasal mucosa	14
19	M/25	Trauma	P.W.	80	IIB. trep	Fascia lata, cartilage fat graft	12
20	M/24	Trauma	P.W.	40	IIB	Nasal mucosa	9
21	F/28	Trauma	P.W.	200	III	Fascia lata, cartilage	8
22	M/32	Trauma	Fr., Ethmoid	30	IIA	Nasal mucosa	7

Study	Number of cases	Etiology	Surgical approach	Reconstruction	Outcome
Shi et al.,²²22 Shi JB, Chen FH, Fu QL, Xu R, Wen WP, Hou WJ, et al. Frontal sinus cerebrospinal fluid leaks: Repair in 15 patients using an endoscopic surgical approach. ORL J Otorhinolaryngol Relat Spec. 2010;72:56–62. 2010	15	Trauma (14), spontaneous (1)	Draf IIa (9), Draf IIb (4), combined open and endoscopic (2)	Inlay muscle, onlay fascia +/− mucosa, bone in > 2 cm defects	Revision for leak (1), revision for frontal stenosis (1)
Jones et al.,¹⁴14 Jones V, Virgin F, Riley K, Woodworth BA. Changing paradigms in frontal sinus cerebrospinal fluid leak repair. Int Forum Allergy Rhinol. 2012;2:22–32. 2012	24	Spontaneous (13), trauma (11)	Draf IIB(21), Draf III (3), Draf IIA+ trephine (1)	Inlay synthetic, onlay mucosa, septal flap (16), bone graft for suspected ICP	Revision for leak (2), revision frontal stenosis (1)
Jahanshahi et al.,¹³13 Jahanshahi J, Zeinalizadeh M, Mohammadi HR, Sadrehosseini SM. Endonasal endoscopic management of frontal sinus cerebrospinal fluid leak. Am J Rhinol Allergy. 2017;31:406–11. 2017	24	Trauma (18), Spontaneous (6), No tumor cases	Draf Iib (20), Draf III (3), Draf IIa (1)	Autografts double layer- Inlay fat/muscle, onlay fascia	Revision for leak (1), revision frontal (1)
Bozkurt et al.,⁶6 Bozkurt G, Zocchi J, Russo F Pietrobon G, Karligkiotis A, Elhassan HA, et al. Frontal sinus preservation during cerebrospinal fluid leak repair. J Craniofac Surg. 2019;30:e763–8. 2019	53	Trauma (26), Iatrogenic (13), Spontaneous (14)	Endoscopic- Draf IIA (5), Draf IIB (5), Draf III (3), Draf III + orbital transposition (4) endoscopic+ OPF (23), endoscopic + craniotomy(13)	autologous materials, triple-layer for large defects, double layer for small defects, gasket-seal	Revision for frontal stenosis (3)
Present study	22	Trauma (17), spontaneous (5)	Draf IIA (3), Draf IIB (9), Draf III (5), Draf IIB + trephine (5)	autologus materials, double layer for small defects, triple layer for large defects (fascia+/− cartilage for defects > 2 cm)	Revision for frontal stenosis (2)

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] * Corresponding author. E-mail: andapstl@yahoo.com (A. Gâta).