Dealing with an Intraoperative CSF Leak

Clear fluid may be seen emanating from a skull base defect (Fig. 12.15). It looks like a clear stream in a pool of blood and it often pulsates. Unless you are aware of this possibility you may miss it. Occasionally an ethmoid air cell full of mucus that is opened will produce a similar appearance, but then the stream stops almost immediately. The edges of the bony defect should be defined. Many graft materials have been used, ranging from a "bath plug" fat graft for small leaks (Wormald and McDonagh, 1997) to a free turbinate or conchal cartilage graft for larger defects (Marshall et al., 2001 a). It is best to place the graft above the defect so that it underlays the defect, but wedging it within the hole also works. This is then overlaid by a free mucosal graft from the inferior turbinate. We have found that a lumbar drain is unnecessary. The graft is supported by a dressing of oxidized cellulose to avoid it sticking to a pack such as a bismuth and iodoform impregnated gauze for 10 days. Both peroperative and postoperative prophylactic antibiotics are given for 10 days. The patient is nursed 30° or more head-up and asked not to strain (e.g., not to lift heavy objects and to avoid becoming constipated). Patients are discharged home after 36 hours. ^yo 15

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