Forty-eight patients entered the study, 4 of them were excluded due to following reasons:
First of all, one patient with a history of previous failed endoscopic repair in which the second evaluation with intrathecal fluorescein showed the middle ear as the site of leakage.
Then, two cases of CSF leakage caused by dural involvement of skull base tumor with intracranial extension that underwent surgical repair using external approach.
Finally, one patient who died of meningitis before endoscopic surgery.
In analysis of demographic variables of 44cases remained in the study, normal distribution of age and gender variables were found. Patients were between 1 - 74 years of age (mean age of 35, SD: 18).
Among the studied patients 19 (43.2%) were female and 25 (56.8%) were male.
The time period passed after surgery ranged from 2 to 29 months (mean = 9 months)
In the follow up period, 3 patients died of underlying disease not related to the surgery, all of them suffered from tumors with skull base involvement (however, none of them showed evidences of recurrent leak).
Additionally, median postoperative hospitalization time was 8.7 day (range 1 - 23 days).
And during the period of study, one of the cases was not available for follow up.
Of 43 operated patients 38 (88.4%) had successful result after first surgical attempt and revision surgery was required for 5 (11.6%) of whom 3 cases were operated (repeated endoscopic repair in 2 and external surgery in 1 patient), all of revision surgeries were successful.
Also 2 patients with failed first operation did not consent for revision surgery. So at the end, there were a total of 40 successful endoscopic repairs.
In 5 failed operation, the mean time until detection of recurrence was 68 days. The failed cases were as follows:
In one patient, repair had been done using only fat tissue.
In 2 cases the site was not found definitely during operation.
In one case the defect was on the lateral site of sphenoid sinus.
One patient had a foveal site of defect which was repaired with standard method using fat and fascial graft.
Table 1 shows etiologies of CSF leak in studied cases.
Table 1.
Frequency of Different Etiologies of CSF Leak in the Studied Group
Etiology | Frequency (%) |
---|
Trauma | 17 (38.6) |
Iatrogenic (due to endoscopic sinus surgery) | 8 (18.2) |
Iatrogenic (due to endoscopic pituitary surgery) | 4 (9.1) |
Spontaneous | 8 (18.2) |
Tumors | 5 (11.4) |
Congenital anomalies | 2 (4.5) |
Total | 44 (100) |
In evaluation of symptoms, all of the patients had presented with unilateral rhinorrhea.
Associated conditions are shown in Table 2.
Table 2.
Frequency of Some Associated Conditions in Studied Patients with CSF Rhinorrhea
Associated Conditions | Frequency (%) |
---|
Headache | 12 (27.3) |
Meningitis | 9 (20.5) |
Seizure | 6 (13.6) |
Pneumocephalus | 4 (9.1) |
Hyposmia | 4 (4.5) |
It should be mentioned here that, the most common sites of defect were ethmoid roof, sphenoid sinus and cribriform plate respectively (Table 3).
Table 3.
Frequency of Defect Sites
Defect Site | Frequency (%) |
---|
Ethmoid roof | 14 (31.8) |
Sphenoid roof | 9 (20.4) |
Cribriform plate | 8 (18.2) |
Frontal sinus | 4 (9.1) |
Lateral lamella | 2 (4.55) |
Not clearly identified | 5 (11.4) |
Not documented in records | 2 (4.55) |
Total | 44 (100) |
Table 4 illustrates various approaches used for surgical repair of CSF leaks.
Table 4.
Different Approaches Used for Defect Repair
Approach | Frequency (%) |
---|
Trans ethmoidal | 30 (68.2) |
Trans sphenoidal | 9 (20.5) |
Trans nasal | 3 (6.8) |
Frontal trephination | 2 (4.5) |
Total | 44 (100) |
Table 5 demonstrates various graft materials applied in studied patients.
Table 5.
Frequency of Different Materials Used for Surgical Repair of Skull Base Defect
Material | Frequency |
---|
Mucosa | 24 |
Muscle | 22 |
Fat | 15 |
Cartilage | 13 |
Fascia lata | 13 |
Temporal fascia | 13 |
Abdominal fascia | 2 |
Vascularized flap | 12 |
Graft placement techniques were not clearly mentioned in 11 cases, of 33 remained patients at least one layer of underlay graft had been used in 19 (43.2%) and total overlay technique was found to be used in 14 (31.8%).
Intra and post-operative lumbar drains were used in 5 of 44 patients. (11.4%), serial postoperative lumbar puncture was used in 5 patients.
In order to determine factors affecting the success of endoscopic repair of CSF leak we did statistical analysis of following variables:
Defect size, number of graft layers, graft placement technique -underlay vs. overlay- lumbar drain placement or serial LPs were evaluated as potential effective factors, and none of them showed a statistically significant association with surgical outcome. Also, intrathecal fluorescein for detection of defect site, did not improve the results.
Review of operative notes exhibited that in more than half of the patients at least one layer of mucosal or fascial graft had been used, and muscle, fat and cartilage were in lower orders of frequency.
By using fisher exact test, no association was found between surgical outcome and history of previous surgery -endoscopic or external- or type of endoscopic approach.
Based on the fisher exact test, definite determination of defect site before or during operation had a relationship with surgical success with a P value of 0.06.
Immediate postoperative improvement of leakage was observed in 31 patients (70.5%), postoperative status in immediate postop period was not mentioned in one case (2.3%) and in 12 cases (27.3%) leak did not stop instantly.
We also evaluated factors influencing immediate postop improvement, etiology of leak, size and site of defect, history of previous surgical treatment, duration of leak, the applied surgical approach, the material used, and graft placement technique did not affect the outcome.
The mean numbers of layers used for defect repair was 2.5 in total studied group, average number of graft layers applied for repair of defect was 3 in 31 patients in whom CSF leak stopped promptly after the operation and it was 2 for other 12.
The t-test was utilized to analyze the immediate post-surgical status according to the number of graft or flap layers used for defect repair which showed a statistically significant association (P value: 0.046).
There was also a significant correlation between the number of layers on the defect site and immediate postoperative improvement based on the Mann-Whitney test (Wilcoxon W) (P value: 0.037).
Also, χ2 test showed a statistically significant relation between the use of muscle tissue as graft material and immediate cessation of leak (P value: 0.03).
In addition, multifactorial logistic regression analysis showed that the relation of muscular graft and immediate leak cessation was not a dependent one, in other words patients with more layers of graft had more muscular tissues as well.
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