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Treatment Guidelines

Although most traumatic CSF fistulas can spontaneously heal with conservative measures such as bed rest, head supraelevation, administration of laxatives and antiemetics, and positioning of a lumbar drainage, a surgical corrective procedure is recommended in case these measures fail within 10-15 days (Hegazy et al. 2000).

Immediate surgical correction is instead indicated in the case of traumatic fistulas associated with intracranial lesions requiring craniotomy and in all cases of iatrogenic leaks occurring during skull base surgery and sinus surgery (Hegazy et al. 2000).

Wigand (1981) first reported the endoscopic en-donasal approach for CSF leaks occurring during mi-croendoscopic sinus surgery for inflammatory conditions. From this first experience, microendoscopic repair gained popularity and is now considered the treatment of choice.

External approaches are still the mainstay in the treatment of frontoethmoidal, spheno-orbital and spheno-maxillary cephaloceles, while nasopharyn-geal lesions may be amenable with a microendo-scopic approach.

A large spectrum of materials can be used for du-raplasty: abdominal fat, septal mucoperichondrium, turbinate bone, temporalis muscle and fascia, cadaver pericardium, lyophilized dura, fascia lata, and hydroxyapatite (Zweig et al. 2000).

Transnasal surgical repair involves mainly three techniques: underlay, overlay and tobacco pouch (Schick et al. 2001). The underlay technique is ideal for defects located in the fovea ethmoidalis (Fig. 7.3). Graft material (bone from the middle turbinate or cartilage from the septum) is positioned between the dura and the skull base or intracranially over the dura. A free mucoperichondral graft, harvested from the septum, is subsequently placed, as a second layer, on the endonasal surface of the skull base to reinforce the plasty.

Dura mater

Dura mater

Fovea Platina Maxilla

Fig. 7.3. Underlay technique. Coronal view of the anterior skull base showing the repair of a defect in the fovea ethmoidalis with "underlay technique." Grafting material (autologous cartilage from nasal septum or bone from middle turbinate) is positioned between the skull base and the dura. A mucosal graft from nasal septum or middle turbinate is placed as a second layer to reinforce the plasty

Fig. 7.3. Underlay technique. Coronal view of the anterior skull base showing the repair of a defect in the fovea ethmoidalis with "underlay technique." Grafting material (autologous cartilage from nasal septum or bone from middle turbinate) is positioned between the skull base and the dura. A mucosal graft from nasal septum or middle turbinate is placed as a second layer to reinforce the plasty

The overlay technique is generally employed for defects located in the lamina cribra, where the presence of olfactory phyla makes it difficult to dissect dura from the adjacent skull base (Fig. 7.4). A free cartilaginous or bony graft is first placed on the extracranial surface of the skull base to close the bony gap; similarly to underlay technique, duraplasty is then completed with a second layer of free mucoperichondrium. This technique can be also used in the lateral wall of extensively pneumatized sphenoid sinuses, where the leak is usually coming from a defect in the floor of the middle cranial fossa. In this setting, extensive drilling of the pterygoid process is required to ensure an adequate exposure (Casiano and Jassm 1999).

The tobacco pouch technique is an alternative procedure for sphenoid sinus defects: after careful removal of the entire mucosa investing the sinus, fascia lata plus Gel foam or abdominal fat is positioned into the sinus and then sealed by a mucoperichondral graft (Weber et al. 1996; Schick et al. 2001) (Fig. 7.5).

A review of the literature indicates high success rates for microendoscopic procedures, varying from 75.9% to 97% after primary repair, up to 100% after revision surgery. These results are independent a b

Coronal View Pterygoid

Fig. 7.4a,b. Overlay technique. a Coronal view of the anterior skull base showing the repair of a defect in the olfactory fossa with "overlay technique." Autologous cartilage or bone and mucosal graft are positioned endonasally under the dural defect. b Coronal view of the middle skull base showing the repair of a defect in the lateral wall of a hyperpneumatized sphenoid sinus with "overlay technique." After drilling of the pterygoid process a double layer plasty is positioned

Pterygoid Process Fracture

Fig. 7.5. Tobacco pouch technique. Axial view of the skull base showing the repair of a defect in the posterior wall of a sphenoid sinus with "tobacco pouch technique." A double layer packing with fascia lata and abdominal fat or Gelfoam is positioned into the sinus

Fig. 7.4a,b. Overlay technique. a Coronal view of the anterior skull base showing the repair of a defect in the olfactory fossa with "overlay technique." Autologous cartilage or bone and mucosal graft are positioned endonasally under the dural defect. b Coronal view of the middle skull base showing the repair of a defect in the lateral wall of a hyperpneumatized sphenoid sinus with "overlay technique." After drilling of the pterygoid process a double layer plasty is positioned

Fig. 7.5. Tobacco pouch technique. Axial view of the skull base showing the repair of a defect in the posterior wall of a sphenoid sinus with "tobacco pouch technique." A double layer packing with fascia lata and abdominal fat or Gelfoam is positioned into the sinus from the surgical technique and grafting materials (Dodson et al. 1994; Burns et al. 1996; Lanza et al. 1996; Castillo et al. 1999; Marshall et al. 1999; Nachtigal et al. 1999; Mao et al. 2000; Zweig et al. 2000; Schick et al. 2001).

Important clues for a successful repair are represented by: precise location and exposure of the defect with adequate removal of the surrounding mucosa, removal of unstable bony fragments around the breech, and use of an oversized graft (Gassner et al. 1999; Castelnuovo et al. 2001; Schick et al. 2001).

An elevated body mass index, a finding frequently associated with spontaneous CSF leak (SchlosseR and Bolger 2003), has also been recently shown to be related with failure of repair (Lindstrom et al. 2004).

Although some authors consider perioperative antibiotic therapy unnecessary, or even contrain-dicated, for potential positive selection of resistant bacteria, it is generally recommended for at least 48 h after surgery to decrease the incidence of postoperative meningitis (Choi and Spann 1996; NachtigaL et al. 1999; Hegazy et al. 2000; Zweig et al. 2000).

Some authors recommend the use of a lumbar drainage and its maintenance for at least 72 h after surgery (Mccormack et al. 1990; Persky et al. 1991; Mao et al. 2000). According to more recent and numerous series, its use should be limited to those patients who have an associated hydrocephalus and/ or intracranial hypertension (Dodson et al. 1994; Casiano and Jassm 1999; Hegazy et al. 2000).

The success rate of the microendoscopic approach (superior to external techniques) and the low incidence of postoperative complications make it the treatment of choice. External approaches are nowadays justified in the case of repeated failures of mi-croendoscopic techniques, multifocal fronto-basal fractures, association with brain lesions requiring craniotomy, and fistulae not endoscopically treatable (posterior wall of the frontal sinus).

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