Rodney J. Schlosser

Nasal Cerebrospinal Fluid Leaks: Critical Review and Surgical Considerations

Otolaryngologists have assumed a major role in the evaluation and management of anterior skull base defects that result in cerebrospinal fluid (CSF) leaks and meningoencephaloceles. To achieve the best possible results for patients with CSF leaks, a thorough understanding of the underlying pathophysiology and a critical analysis of management principles and treatment options is essential. Surgical and medical management of these patients is highly individualized and depends on a number of factors, including etiology, anatomic site, patient age, and underlying intracranial pressure. This review article will highlight the history, physiology, pathophysiology, diagnosis, surgical techniques, and postoperative care relevant to nasal CSF leaks and encephaloceles.

Spontaneous Cerebrospinal Fluid Leaks: A Variant of Benign Intracranial Hypertension

Objectives: Previous reports indicate that elevated intracranial pressure (ICP) may cause spontaneous cerebrospinal fluid (CSF) leaks. In this study we examined the clinical diagnosis of benign intracranial hypertension (BIH) in this population using the modified Dandy criteria. Methods: We performed a retrospective review of clinical data and measurements of ICPs after surgical repair. Results: Sixteen patients with spontaneous CSF leaks were surgically treated from 1996 to 2002. In 11 patients with CSF pressure measurements, strict adherence to the modified Dandy criteria definitively confirmed a diagnosis of BIH in 8 patients (72%) and a likely diagnosis in the 3 remaining patients. The mean ICP was 31.1 cm H2O (range, 17.3 to 52 cm H2O), and 81% of the patients were obese middle-aged women. Clinically, all patients had signs and/or symptoms of elevated ICP, such as headache (91%), pulsatile tinnitus (45%), hypertension (45%), balance problems (27%), and visual complaints (18%). Surgical repair was 100% successful in leak cessation over a mean follow-up of 14.1 months. Conclusions: Most patients with spontaneous CSF leaks fulfill the modified Dandy criteria; thus, this disorder appears to be a variant of BIH. Further investigation is needed to determine the exact cause of elevated CSF pressures in this group and whether medical or surgical treatments to correct the intracranial hypertension are warranted.

Effects of endoscopic sinus surgery and delivery device on cadaver sinus irrigation

Objective Assess paranasal sinus distribution of topical solutions following endoscopic sinus surgery (ESS) using various delivery devices. Study Design Experimental prospective study. Subjects and Methods Ten cadaver sinus systems were irrigated with Gastroview before surgery, after ESS, and after medial maxillectomy. Delivery was via pressurized spray (NasaMist), neti pot (NasaFlo), and squeeze bottle (Sinus Rinse). Scans were performed before and after each delivery with a portable CT machine (Xoran xCAT), and blinded assessments were made for distribution to individual sinuses. Results Total sinus distribution was greater post-ESS (P < 0.001). Additional distribution was gained with medial maxillectomy (P = 0.02). Influence of delivery device on distribution was significantly higher with neti pot > squeeze bottle > pressurized spray (P < 0.001). Frontal sinus penetration was greatest after surgery (P = 0.001). Conclusion ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Pressurized spray solutions in un-operated sinuses provide little more than nasal cavity distribution. Use of squeeze bottle/neti pot post-ESS offers a greatly enhanced ability to deliver solutions to the paranasal sinuses.

Spontaneous CSF leaks : A paradigm for definitive repair and management of intracranial hypertension

Objective To report our outcomes with the repair of spontaneous cerebrospinal fluid (CSF) leaks and to demonstrate how management of underlying intracranial hypertension improves outcomes. Study Design Retrospective review of spontaneous CSF leaks treated at the University of Pennsylvania Health System from 1996 to 2006. Data collected included demographics, nature of presentation, body mass index (BMI), site of skull base defect, surgical approach, intracranial pressure, and clinical follow-up. Results Fifty-six patients underwent repair of spontaneous CSF leaks. Eighty-two percent (46 of 56) were obese (average BMI 36.2 kg/m2). Nine patients had multiple CSF leaks. Fifty-four patients (96%) had associated encephaloceles. Fifty-three CSF leaks (95%) were successfully repaired at first attempt (34 months of follow-up). Intracranial pressures averaged 27 cm H2O. Patients were treated with acetazolamide or, in severe cases, with a ventriculoperitoneal shunt. Conclusions Spontaneous CSF leaks have the highest recurrence rate of any etiology. With treatment of underlying intracranial hypertension coupled with endoscopic repair, the success rate (95%) approaches that of other etiologies of CSF leaks.

Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks.

Background Spontaneous cerebrospinal fluid (CSF) leak is a condition that previously has been considered idiopathic and classified as having “normal” intracranial pressure (ICP). We present clinical and radiographic evidence that indicates elevated ICP in this group. In addition, we review the pathophysiology and unique management issues in caring for patients with spontaneous CSF leak. Methods We present a retrospective review of medical records, imaging studies, ICP measurements, and surgical treatment of patients with spontaneous CSF leaks. Results Sixteen patients with spontaneous CSF leaks were surgically treated from 1996 to 2002. Ten patients underwent postoperative lumbar puncture with CSF pressure measurement during clinically indicated computed tomography cisternograms. Intracranial pressures were elevated in all 10 patients, with a mean of 26.5 cm H2O and a range of 17.3–34 cm H2O, (normal, 0–15 cm H2O). Demographically, 13/16 patients were women, all were middle-aged with a mean age of 49.6 years, and 15/16 patients were obese with a mean body mass index of 35.9 kg/m2. Radiographically, 15 patients had imaging of the sella turcica, 10 patients had completely empty sellas, and 5 patients had partially empty sellas. Surgical repair was 100% successful in leak cessation with a mean follow-up of 14.1 months. Conclusion Although the precise cause and mechanism of spontaneous CSF leaks is not fully understood, this study sheds light on important factors to consider. Patients with this condition have similar physical and radiographic findings such as middle-aged, female gender, obesity, and empty sella. Additional investigation is needed to determine the exact cause of the condition, its relationship to elevated ICPs, and if further medical or surgical treatments to correct the intracranial hypertension are warranted.

Health state utility values in patients undergoing endoscopic sinus surgery.

The primary study goal was to measure health state utility values in patients with chronic rhinosinusitis (CRS) before and after undergoing endoscopic sinus surgery (ESS). A secondary goal was to assess the meaning of these values by comparing them with other chronic disease processes and currently available medical or surgical treatments.

Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi‐institutional study with 1‐year follow‐up

This study evaluated 1‐year outcomes in patients with chronic rhinosinusitis (CRS) who were considered surgical candidates by study criteria and elected either medical management or endoscopic sinus surgery (ESS). In addition, some patients initially enrolled in the medical treatment arm crossed over to the surgery arm during the study period and their respective outcomes are evaluated.

Topical therapies in the management of chronic rhinosinusitis: an evidence-based review with recommendations

Topical therapies have become an integral component in the management plan for chronic rhinosinusitis (CRS). Several topical therapy strategies have been evaluated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence‐based approach for the utilization of topical therapies in the management of CRS.

Productivity Costs in Patients with Refractory Chronic Rhinosinusitis

Disease‐specific reductions in patient productivity can lead to substantial economic losses to society. The purpose of this study was to: 1) define the annual productivity cost for a patient with refractory chronic rhinosinusitis (CRS) and 2) evaluate the relationship between degree of productivity cost and CRS‐specific characteristics.

Comparison of techniques for transsphenoidal pituitary surgery.

Background The aim of this study was to compare three different techniques for transsphenoidal pituitary surgery: (1) sublabial transseptal approach with microscopic resection, (2) transnasal transseptal approach with endoscopic resection, and (3) endoscopic approach with endoscopic resection. Methods We performed a retrospective review of 50 pituitary surgeries performed by the same neurosurgeon. Demographic, radiographic, and clinical data were collected. Results Fifteen patients underwent sublabial approach with microscopic tumor resection, 21 patients underwent the transnasal approach with endoscopic resection, and 14 patients underwent the completely endoscopic technique. There were a total of 20 complications in the sublabial group, 13 transnasal complications, and 6 endoscopic complications. Cerebrospinal fluid leak incidence was 53% in the sublabial approaches, 47% transnasal, and 28% in the endoscopic patients. Diabetes insipidus was encountered in 33% of sublabial approaches, 5% of transnasal approaches, and 7% of endoscopic approaches. Lumbar drains were required in 40% of sublabial approaches, 38% of transnasal approaches, and 7% of endoscopic approaches. Nasal packing was used in 100% of sublabial and transnasal approaches and 0% of endoscopic approaches. Mean recurrence rate and follow-up was sublabial in 6.6% (50 months), transnasal in 9.5% (11 months), and endoscopic in 0% (7 months). Average hospital stay for sublabial approaches, transnasal approaches, and endoscopic approaches was 8.3, 6.2, and 3.4 days, respectively (p < 0.05). Conclusion Transsphenoidal pituitary surgery has evolved over the past several decades, because advances in technology have been the catalyst for minimally invasive surgeries. Less invasive approaches, such as the transnasal approach with endoscopic resection of tumor and the completely endoscopic technique have less morbidity and a shorter hospital stay than traditional sublabial approaches. Continued follow-up is needed to confirm long-term benefits and similar recurrence rates.