Tiffany Baugh, MD Matthew Page, MD 1/21/2015 CSF LEAK AND ENDOSCOPIC SINUS SURGERY
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1 Tiffany Baugh, MD Matthew Page, MD 1/21/2015 CSF LEAK AND ENDOSCOPIC SINUS SURGERY
2 Outline Anatomy Diagnosis intra-op Diagnosis post-op Treatment/Management Cases
3 Question Important Anatomical Considerations
4 Anatomy Hosemann, W and Draf C. Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Current Topics Otorhinolaryngology Head and Neck Surgery...
5 Maxillary/Ethmoid Height Ratio of maxillary-to-ethmoid height, vary 1:1 to 2:1 Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America.
6 Fovea Ethmoidalis and Orbit Meyers, R and Valvassori, G. Interpretation of anatomic variations of computed tomography scans of the sinuses: a surgeon s perspective. Laryngoscope
7 High: > 7 mm. = 70% patients Moderate: 4-7 mm. = 25% patients Low: < 4 mm. = 5% patients Rudmik, L and Smith, T. Evaluation of the Ethmoid Skull Base Height Prior to Endoscopic Sinus Sugery: A Preoperative CT evaluatin Technique. Internation Forum of Allergy and Rhinology.
8
9 Protein-sstructure.net
10 University of Washington
11 Keros Classification Palmer, J and Chiu, A. Atlas of Endoscopic Sinus and Skull Base Surgery
12 Keros Classification Palmer, J and Chiu, A. Atlas of Endoscopic Sinus and Skull Base Surgery
13 Anatomic Variants a. Position of the ethmoid roof beneath the roof of the orbit. b. Asymmetry of the ethmoid roof. c. Asymmetry regarding the height of the ethmoid roof (in 2/3 the right side is lower than the left). d. Deep position of the cribriform plate, i.e. high lateral lamella of the olfactory fossa. e. Larger angle between the skull base and the horizontal line through the sagittal plane. Hosemann, W and Draf C. Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Current Topics Otorhinolaryngology Head and Neck Surgery
14 Epidemiology <1% Posterior Ethmoid Roof Lateral lamella of the cribriform plate Single most important risk factor- prior FESS Eisele, D and Smith, R. Complications in Head and Neck Surgery
15 3402 patients 19 leaks 71% prior surgery 82% image guidance* 11% polyps 13% Keros grade 3
16 Surgery US institute for Advanced Sinus Care and Research
17 Diagnosis- intraop Clear fluid Pulsating dura/brain Increase in bleeding
18 Carrau, R et al. Complications of Endoscopic Sinus Surgery: Csf leak. Operative Otolaryngology: Head and Neck surgery
19 Management Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America.
20 Management Stop, lightly pack nose with pledgets in 1:100,000 epinephrine over site Flatten table Dose of Ceftriaxone Review Scan Hemostasis Identify leak Reefy, H and Hopkins, C. Up to date expert opinion referencing the best evidence available on intraoperative cerebrospinal fluid leak during endoscopic sinus surgery. Clinical Otolaryngology.
21 Leak Cannot identify location Identify leak but minimal repair Identify but do not feel comfortable with repair Identify with large repair
22 Conservative Management Deep extubation Antiemetics Elevate Head of Bed No straining, nose blowing, heavy lifting Lumbar drain? Antibiotics? Post op Imaging Counseling Re-evaluate Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America.
23 Repair Prepare site Maxillary antrostomy, total ethmoidectomy, poss middle turbinate Strip mucosa Measure, Consider shrinkage of graft Grafts Overlay, Underlay, Combined Cartilage, bone, mucoperichondrium, mucosa, fascia, fat, synthetic materials Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America.
24 Repair Size <2mm Osteoneogenesis, fibrosis, overlay graft 2-5mm Composite graft >5mm multilayered Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America.
25 Bath-plug technique Prepare site Harvest fat (earlobe, abdomen) Same diameter as defect, 2-3x long Mucosa graft harvested (lateral nasal wall) 4-0 Vicryl suture Ball probe to place fat Mucosal graft over defect Fibrin glue Reefy, H and Hopkins, C. Up-to-date expert opinion referencing the best evidence available on intraoperative cerebrospinal fluid leak during endoscopic sinus surgery. Clinical Otolaryngology.
26 Composite Middle turbinate graft Resect at skull base Strip mucosa from one side Remove excess bone, leave behind mucoperiosteum Wedge into defect Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America.
27 Multilayer Lorenz RR, Dean RL, Hurley DB, Chuang J, Citardi MJ. Endoscopic reconstruction of anterior and middle cranial fossa defects using acellular dermal allograft. Laryngoscope.
28 Prosser, J et al. traumatic Cerebrospinal fluid Leaks. The Otolaryngolgoic clinics of North America.
29 Repair-Ethmoid/Cribiform plate Fibrin glue Packing- gelfoam Nonabsorbable
30 Repair-Sphenoid Sinus Similar ideas for repair Do not strip mucosa too far laterally
31 Repair-Frontal sinus Instrumentation Stent Prosser, J et al. traumatic Cerebrospinal fluid Leaks. The Otolaryngolgoic clinics of North America.
32 Successful Repair 2012 Psaltis, et al Systematic Review of Endoscopic Repair of CSF leaks 90%- primary surgery 97% - secondary surgery
33 Antibiotics Controversial Perioperative Post-op Packing Majority of meningitis occurs in first year, decreases with time Persistent leak- always risk
34 Lumbar Drain Decrease ICP and Reduce flow through defect Intracranial hypertension Consider if initial management fails Increases length of stay Prosser, J et al. traumatic Cerebrospinal fluid Leaks. The Otolaryngolgoic clinics of North America.
35 Post-op Deep extubation Elevate Head of Bed No straining, nose blowing, heavy lifting Imaging ICU Prosser, J et al. traumatic Cerebrospinal fluid Leaks. The Otolaryngolgoic clinics of North America.
36 Management Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America.
37 Alternate Scenario Delayed diagnosis
38 Diagnosis- post op Clear nasal drainage May be related to posture Retained saline rinse? Salty, metallic Changes in smell Headache, may improve after rhinorrhea Pneumocephalus Meningitis Brain abscess Prosser, J et al. traumatic Cerebrospinal fluid Leaks. The Otolaryngolgoic clinics of North America.
39 Evaluation Exam Lean forward, valsalva Halo sign Endoscopy Labs Glistening mucosa Glucose Β-2 transferrin B-trace protein Cummings Otolaryngology Head and Neck Surgery, CH. 54
40 Glucose Glucose Oxidase test strips High false positive rate Tears, mucus False negative- bacterial meningitis Cummings Otolaryngology Head and Neck Surgery, CH. 54
41 B-2 transferrin Preferred marker of CSF Need adequate sample Frozen Limit transportation time Result time Detected in aqueous humor, chronic liver disease, rare glycoprotein disorders Cummings Otolaryngology Head and Neck Surgery, CH. 54
42 B-trace protein Produced by meninges/choroid plexus Also in other bodily fluids but lower concentrations Unreliable- renal insufficiency, bacterial meningitis Cummings Otolaryngology Head and Neck Surgery, CH. 54
43 Imaging CT CT cisternography Nasal endoscopy with Intrathecal Fluorescein Radionuclide Cysternography MRI (cysternography)
44 Cummings Otolaryngology Head and Neck Surgery, CH. 54
45 CT cisternogram Skull base CT in axial plane 5-7 ml of nonionic contrast in intrathecal space head down confirm flow with fluoro valsalva cor onal/axial CT 80% success Head and neck imaging CH. 5
46 Nasal Endoscopy with Intrathecal Fluorescein Off label Requires LP Lean forward, examine ARS CSF Leak Complications of intrathecal fluorescein reports of grand mal seizures, death Complications are isolated and occur at high dose Keerl et al low dose (<50mg) is unlikely to cause adverse events Recommended dilution 0.1 ml of 10% fluorescein (IV preparation) diluted in 10 cc of pts CSF
47 Radionuclide Cysternography Various radiolabled tracers such as: Radioactive Iodine labeled serum albumin (RISA) Diethylenetriamine/pentaacetic acid (DTPA) Requires LP Scintillation Camera detects radiolabeled tracer Intranasal pledgets placed in areas of concern and are assessed with gamma counter hours later Elevated pledget : serum count ratio consistent with a leak
48 Radionuclide Cysternography Drawback poor spatial visualization Medscape. CSF Leak Imaging.
49 Repair Location Ethmoid Sinus Roof and Cribriform Plate Sphenoid Sinus Frontal Sinus
50 Persistent Leak Insufficient localization of defect Previous surgeries History of craniotomy History of radiotherapy Intracranial infection Intracranial hypertension Hosemann, W and Draf C. Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Current Topics in Otorhinolaryngology Head and Neck Surgery
51 Complications Pneumocephalus Subdural hematoma Intracranial hemorrhage Contusion Cerebritis Meningitis Abscess
52 Complications Head and neck imaging, CH. 5
53 Complications Head and Neck imaging, Ch. 5
54 Complications Head and Neck Imaging, Ch. 5
55 Complications Head and Neck Imaging, Ch. 5
56 Complications Head and Neck Imaging. Ch. 5
57 Prevention 1. Assess the integrity of the skull base on a coronal computed tomography (CT) scan. 2. Identify the Keros class of the medial skull base on a coronal CT scan. 3. Estimate the posterior ethmoid height and the slope of skull base on coronal and sagittal CT scans. 4. Avoid medial and superior dissection during ethmoidectomy. 5. Penetrate the basal lamella medially and inferiorly. 6. Identify the skull base at the sphenoid face, and then dissect the skull base retrograde. 7. Use a 0-degree scope for ethmoid dissection and a 30-degree scope for skull-base dissection. 8. Palpate behind all septations before removal. Carrau, R et al. Complications of endoscopic sinus surgery: CSF leak. Operative otolaryngology: head and neck surgery.
58 Septoplasty Delayed Injury Stress forces transmitted to cribriform via perpendicular plate of the ethmoid bone Exam- Slit type defects at horizontal lamella of cribriform plate Soni, R et al. Postoperative cerebrospinal fluid leak after septoplasty: A potential complication of occult anterior skull base encephalocele. Allergy Rhinology.
59 Balloon sinuplasty Case report 36yF 3 weeks after frontal sinus balloon sinuplasty presented with fever, headache, nausea Tip of device penetrated through lateral lamella of the cribiform plate intraoperatively Tomazic, P et al. Ethmoid Roof CSF leak following frontal sinus balloon sinuplasty. Rhinology
60 CASE AE History: Diagnosed with encephalocele in 2006 Clear rhinorrhea x 1 year Recently underwent esophageal surgery with prolonged intubation
61 CASE AE Exam: Polypoid structure obscuring right nasal passage
62 CASE AE Imaging
63 Questions? American College of Veterinary Radiology
64 LSU College of Agriculture
65 References Hosemann, W and Draf C. Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Current Topics in Otorhinolaryngology Head and Neck Surgery Welch, K and Palmer, J. Intraoperative Emergencies During Endoscopic Sinus Surgery:CSF Leak and Orbital Hematoma. The Otolaryngologic Clinics of North America Vol. 41, Issue 3. Meyers, R and Valvassori G. Interpretation of anatomic variations of computed tomography scans of the sinuses: a surgeon s perspective. Laryngoscope Mar, 108. Rudmik, L and Smith, T. Evaluation of the Ethmoid Skull Base Height prior to Endoscopic Sinus Surgery: A preoperative CT evaluation Technique. International forum on Allergy and Rhinology Mar-Apr; 2(2). Palmer, J and Chiu, A. Atlas of Endoscopic Sinus and Skull Base Surgery Eisele, D and Smith, R. Complications in Head and Neck Surgery Stankiewicz, J et al. Complications in endoscopic sinus surgery for chronic rhinosinusitis: A 25 year experience. Laryngoscope Dec, 121. Carrau, R et al. Complications of endoscopic sinus surgery: CSF leak. Operative otolaryngology: head and neck surgery. Ch Reefy, H and Hopkins, C. Up-to-date expert opinion referencing the best evidence available on intraoperative cerebrospinal fluid leak during endoscopic sinus surgery. Clinical Otolaryngology Vol 38. Prosser, J et al. Traumatic Cerebrospinal Fluid Leaks. The Otolaryngologic Clinics of North America Vol 44, Issue 4. Cummings. Otolaryngolgoy Head and Neck Surgery. Ch. 54 CSF rhinorrhea. Som, P and Curtin, H. Head and Neck Imaging. 5 th edition. Ch. 5 Soni, R et al. Postoperative cerebrospinal fluid leak after septoplasty: A potential complication of occult anterior skull base encephalocele. Allergy Rhinology Tomazic, P et al. Ethmoid Roof CSF leak following frontal sinus balloon sinuplasty. Rhinology Lorenz RR, Dean RL, Hurley DB, Chuang J, Citardi MJ. Endoscopic reconstruction of anterior and middle cranial fossa defects using acellular dermal allograft. Laryngoscope Mar;113(3):
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