Cerebrospinal Fluid Rhinorrhea

Comprehensive Guide to Evaluation and Management

1st Edition - January 19, 2023
Editors: Raj Sindwani, Christopher Roxbury
Language: English
Hardback ISBN:
9 7 8 - 0 - 3 2 3 - 8 7 0 7 2 - 6
eBook ISBN:
9 7 8 - 0 - 3 2 3 - 8 7 0 7 1 - 9

Offering up-to-date, multidisciplinary coverage of this nuanced and evolving field, Cerebrospinal Fluid Rhinorrhea provides a comprehensive overview of the evaluation and… Read more

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Offering up-to-date, multidisciplinary coverage of this nuanced and evolving field, Cerebrospinal Fluid Rhinorrhea provides a comprehensive overview of the evaluation and diagnosis, as well as the medical and surgical management options, for all causes of cerebrospinal fluid (CSF) rhinorrhea. It covers all aspects of CSF leaks, synthesizing current knowledge on pathophysiology, diagnosis, perioperative care, and operative techniques for this complex group of patients. Leading experts in otolaryngology and neurosurgery, as well as ophthalmology, neurology, and radiology, provide detailed coverage of the distinctions between management of patients with differing etiologies of CSF rhinorrhea, including spontaneous, traumatic/iatrogenic, and tumor-related.

Cover image
Title page
Table of Contents
Copyright
Dedication
Foreword
Contributors
Video contents
List of Tables
List of Illustrations
PART I. Evaluation and Diagnosis of Cerebrospinal Fluid Rhinorrhea
1. Categorizing cerebrospinal fluid leaks: A framework for understanding
Introduction
Diagnostic tests
Localization of the site of the cerebrospinal fluid leak
Closure techniques
Lumbar drain
Conclusion
References
2. Evaluation of the patients with cerebrospinal fluid leaks: History and physical examination
Introduction
Cause
Symptoms and presentation
Differential diagnosis
Patient features and demographics
Physical examination
Endoscopic examination
Conclusion
References
3. Confirmatory testing for cerebrospinal fluid rhinorrhea
Introduction
Chemical markers
Summary
References
4. Role of imaging studies in the evaluation and localization of cerebrospinal fluid leaks
Introduction
Imaging protocols
Summary
References
PART II. Cerebrospinal Fluid Physiology and Anatomy of the Cranial Base
5. Cerebrospinal fluid physiology and dynamics
Introduction
Physiology
Cerebrospinal fluid bulkflow
Cerebrospinal fluid dynamics
Conclusion
References
6. Surgical anatomy of the anterior cranial fossa
Introduction
Macroscopic anatomy
Endoscopic anatomy
Conclusion
References
7. Surgical anatomy of the middle cranial fossa
Introduction
Intracranial aspect
Extracranial aspect
References
8. Surgical anatomy of the posterior cranial fossa
Introduction
Anatomy of the posterior fossa
Cerebrospinal fluid leakage arising from the posterior cranial fossa
Conclusion
References
PART III. Traumatic and Iatrogenic Cerebrospinal Fluid Leaks
9. Pathophysiology and clinical evaluation of iatrogenic cerebrospinal fluid rhinorrhea after sinus surgery
Introduction
Preoperative anatomic risk factors
Preoperative physiologic risk factors
Risk of iatrogenic cerebrospinal fluid leak based on surgical intervention
Risk of instrumentation
Evaluation of iatrogenic cerebrospinal fluid leak
Conclusion
References
10. Pathophysiology and clinical evaluation of blunt force and penetrating trauma of the anterior cranial base
Introduction
Anterior cranial fossa anatomy
Pathophysiology of traumatic cerebrospinal fluid leak of the anterior cranial fossa
Clinical evaluation
Conclusion
References
11. Imaging of anterior skull base trauma
Introduction
Imaging anatomy
Imaging modalities
Imaging findings
Conclusion
References
12. Surgical management of iatrogenic cerebrospinal fluid rhinorrhea
Introduction
Pathophysiology and presentation
Surgical repair
Repair strategy and considerations
Postoperative care
Conclusion
References
13. Surgical management of large traumatic anterior cranial base defects via craniotomy
Introduction
Epidemiology
Diagnosis and indications for surgery
Surgical exposure
Craniotomy and fracture elevation techniques
Frontal fossa floor exploration and dural repair
Closure and reconstruction
Perioperative management
Long-term complications
Conclusion
References
14. Postoperative management of traumatic cranial base defects
Introduction
Anatomic and structural factors impacting the risk of repair failure
Patient factors impacting the risk of postoperative cerebrospinal fluid leak
Medical management after skull base leak repair
Temporary and permanent cerebrospinal fluid diversion
Conclusion
References
PART IV. Spontaneous Cerebrospinal Fluid Leaks and Idiopathic Intracranial Hypertension
15. Pathophysiology of spontaneous cerebrospinal fluid leaks and their relationship with idiopathic intracranial hypertension
Introduction
Evidence for a relationship between spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension
Pathophysiology of spontaneous cerebrospinal fluid leak
Conclusion
References
16. Diagnosis and medical management of idiopathic intracranial hypertension
Introduction
Pathophysiology
Diagnosis
Medical management
Conclusion
References
17. Surgical management of refractory idiopathic intracranial hypertension
Introduction
Pathophysiology of idiopathic intracranial hypertension: The role of venous system obstruction and sinus stenosis
Cerebral venous sinus system
Surgical treatment
Conclusion
References
18. Ophthalmologic evaluation of idiopathic intracranial hypertension
Introduction
Patient history
Ocular examination
Ancillary testing
Follow-up
Special considerations
Conclusion
References
19. Radiologic findings in idiopathic intracranial hypertension
Introduction
Imaging techniques
Conclusion
References
20. Evaluation and management of congenital skull base defects
Introduction
Pathophysiology
Clinical presentation
Differential diagnosis
Workup
Treatment
Prognosis
Conclusion
References
21. Surgical management of spontaneous cerebrospinal fluid leak of the cribriform plate
Introduction
Anatomy
Preoperative considerations
Instrumentation
Surgical procedure
Postoperative considerations
Conclusion
References
22. Surgical management of lateral sphenoid recess meningoencephaloceles and cerebrospinal fluid leaks
Introduction
Preoperative planning
Surgical approaches to repair of lateral recess of the sphenoid sinus cerebrospinal fluid leaks
Conclusion
References
23. Surgical m anagement of spontaneous cerebrospinal fluid rhinorrhea arising from clival defects
Introduction
Classification
Anatomy
Embryology
Patient presentation
Pathophysiology
Treatment
Conclusion
References
24. Postoperative management after cerebrospinal fluid leak repair in patients with idiopathic intracranial hypertension
Introduction
Postoperative management
Exercise and air travel
Follow-up
Conclusion
References
PART V. Endoscopic Cerebrospinal Fluid Leak Repair and Skull Base Reconstruction and After Tumor Surgery
25. Clinical evaluation of the sellar mass patient
Introduction
Risk factors for a cerebrospinal fluid leak
Additional thoughts
Conclusion
References
26. Clinical evaluation of patients with skull base malignancies
Introduction
History and presentation
Physical examination
Nasal endoscopy
Imaging
Biopsy
Surgical considerations
Multidisciplinary tumor board
Follow-up
Conclusion
References
27. Radiologic evaluation of skull base masses
Introduction
Preoperative imaging
Postoperative imaging
Postsurgical complications
Conclusion
References
28. Decision making in endoscopic skull base reconstruction: A graduated approach
Introduction
Evolution of reconstructive techniques
Risk factors for postoperative cerebrospinal fluid leak
Decision-making process
Quality control
Unanswered questions
Conclusion
References
29. The nasoseptal flap: The workhorse for skull base reconstruction
Introduction
Anatomy
Surgical technique
Outcomes
Conclusion
Acknowledgment
References
30. Locoregional pedicled flap options for skull base reconstruction
Introduction
Intranasal vascularized flaps
Extranasal vascularized flaps
Conclusion
References
31. Sellar reconstruction after pituitary adenoma resection
Introduction
Risk factors
Sellar reconstruction in cases without intraoperative cerebrospinal fluid leak
Sellar reconstruction in mid-risk cases and low-flow leaks
Sellar reconstruction in high-risk cases
Lumbar drain
Revision cases
Conclusion
References
32. Reconstruction after transtuberculum and transplanum approaches to suprasellar pathology
Introduction
Historical perspective on reconstructive approaches
Preoperative considerations
Operative steps and reconstructive approaches
Pearls and pitfalls
Conclusion
References
33. Endoscopic reconstruction of anterior cranial fossa defects
Introduction
Preoperative considerations
Surgical management
Specific considerations
Postoperative management
Conclusion
References
34. Endoscopic reconstruction of middle cranial fossa defects
Introduction
Middle cranial fossa skull base anatomy
Causes
Presentation and demographics
Workup and management
Postoperative management
Conclusion
References
35. Endoscopic reconstruction of posterior cranial fossa defects
Introduction
Surgical techniques
Reconstruction technique
Postoperative care
Results
Conclusion
References
36. Transorbital and transfrontal approaches to cerebrospinal fluid leak repair
Introduction
Indications and contraindications
Preoperative considerations
Surgical technique
Reconstruction
Postoperative management
Outcomes
Conclusion
References
37. Free flap reconstruction of skull base defects
Introduction
Classification of skull base defects
Goals of treatment
Factors to consider in flap selection
Commonly used microvascular free flaps for skull base reconstruction
Anterolateral thigh free flap
Radial forearm free flap
Latissimus dorsi free flap (Fig. 37.5)
Serratus anterior free flap
Scapular and parascapular fasciocutaneous and osteofasciocutaneous free flaps
Fibula free flap
Rectus abdominus free flap
Complications
Conclusion
References
38. Postoperative management after reconstruction following skull base tumor surgery
Introduction
Risk factors and risk stratification paradigms
Postoperative management
Complications
References
PART VI. Cerebrospinal Fluid Diversion and Advances in Instrumentation and Biomaterials
39. Role of cerebrospinal fluid diversion in cerebrospinal fluid leak repairs and skull base surgery
Introduction
Spontaneous cerebrospinal fluid leaks
Acetazolamide
Lumbar drainage
Shunting
Iatrogenic (presurgical and postsurgical)
Pituitary tumors
Larger anterior skull base defects
Fluorescein
Cerebrospinal fluid leaks of the middle and posterior fossa
Traumatic cerebrospinal fluid leaks
Conclusion
Disclosures
Financial support
Acknowledgments
References
40. Advances in endoscopic visualization and surgical navigation
Introduction
Defining optimal imaging characteristics
Three-dimensional endoscopic systems
Fluorescence
Surgical navigation
Conclusion
References
41. Powered instrumentation and bipolar technology in endoscopic endonasal skull base surgery
Introduction
Powered instrumentation
Aquamantys
Conclusion
References
42. Evolution of synthetic graft materials and dural sealants for cerebrospinal fluid leak repair
Introduction
Autologous versus synthetic grafts
Acellular human dermis
Engineered collagen products
Porcine small intestine submucosa
Absorbable dural sealants and glues
Rigid support grafts
Imaging characteristics of synthetic materials in skull base repair
Conclusion
References
Index

Raj Sindwani

Raj Sindwani MD, FACS, FRCS(C) is Vice Chairman and Head of the Section of Rhinology, Sinus and Skull Base Surgery of the Head and Neck Institute at the Cleveland Clinic. He is also Co-Director of the Minimally Invasive Cranial Base and Pituitary Program of the Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center and Fellowship Co-Director of the Advanced Rhinology and Skull Base Surgery Program. Dr. Sindwani is currently President-Elect of the Cleveland Clinic Medical Staff and a member of the Board of Governors. Dr. Sindwani is currently the Editor-in-Chief of the American Journal of Rhinology and Allergy, and past Editor-in-Chief of the Yearbook of Otolaryngology. Dr. Sindwani is an established authority on the medical and surgical management of conditions affecting the sinuses and skull base, and he pioneered endoscopic surgical approaches. He has published and lectured extensively in the field of Rhinology and Skull Base Surgery.

Affiliations and expertise

Section Head, Rhinology, Sinus and Skull Base Surgery, Quality Improvement Officer (QIO), Head and Neck Institute, Cleveland Clinic , Cleveland, Ohio

Christopher Roxbury

Christopher R. Roxbury, MD, FARS is an assistant professor and the director of endoscopic skull base surgery in the section of otolaryngology-head and neck surgery at the University of Chicago. Dr. Roxbury is a Fellow of the American Rhinologic Society, where he serves as an active member on several committees. He has published several peer-reviewed articles discussing the epidemiology, management, and postoperative outcomes of patients suffering from rhinologic and anterior cranial base diseases. He serves as an ad hoc editor for several otolaryngology and neurosurgery journals, including International Forum of Allergy and Rhinology, Laryngoscope, American Journal of Rhinology and Allergy, and World Neurosurgery. Dr. Roxbury is a regular speaker at national rhinology and skull base surgery conferences and has also lectured internationally on reconstructive techniques for cerebrospinal fluid leaks.

Affiliations and expertise

Assistant Professor and The Director of Endoscopic Skull Base Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois

Life sciences

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