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      Transnasal endoscopic and combined intra–extranasal approach for the surgical treatment of frontal sinus cerebrospinal fluid rhinorrhea

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          Abstract

          The aim of this study was to summarize and analyze the outcomes of frontal sinus cerebrospinal fluid rhinorrhea (FS-CSFR) treated by transnasal endoscopic and combined intra–extranasal approach. Clinical data on 20 cases of FS-CSFR patients from 2005 to 2013, with emphasis on the postoperative complications, clinical outcomes, and key technology involved in the combined intra–extranasal procedure, were retrospectively reviewed. Among the 20 cases, 12 were treated by combined intra–extranasal procedure; the other eight cases were initially treated by trans-nasal endoscopic approach alone, and five of them (5/8, 62.5%) were successfully treated and three failed. The three failed cases subsequently underwent combined intra–extranasal approach. A total of 15 cases, who received combined procedure, experienced fast recovery, had mild complications, and had no significant facial scars, and no CSFR recurrence was observed. Combined intra–extranasal approach offers advantages in not only overcoming the difficulty of insufficient exposure of defects during transnasal endoscopic procedure but also improving the success rate of repair.

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          Most cited references 14

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          Transnasal ethmoidectomy under endoscopical control.

           M E Wigand (1981)
          Endonasal sinus surgery aims at the preservation of a lining mucosa in the reventilated and redrained cavities. It can, therefore, be confined to the removal of narrowing bone at the "isthmus" of the ducts or windows. Transnasal ethmoidectomy for diffuse polyposis consists of the removal of the ethmoidal cell septa, including the middle turbinate, and a broad fenestration of both the sphenoid sinus and the frontal infundibulum. A consequent postoperative care provided, transnasal ethmoidectomy offers excellent clinical results. A new suction-irrigation endoscope and refined instruments contribute to improved surgical exposure and to the avoidance of complications.
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            Surgical challenge: endoscopic repair of cerebrospinal fluid leak

            Background Cerebrospinal fluid leaks (CSF) result from an abnormal communication between the subarachnoid space and the extracranial space. Approximately 90% of CSF leak at the anterior skull base manifests as rhinorrhea and can become life-threatening condition. Endoscopic sinus surgery (ESS) has become a common otolaryngologist procedure. The aim of this article is to consider our experience and to evaluate the outcomes in patients who underwent a purely endoscopic repair of CSF leaks of the anterior skull base. Findings Retrospective chart review was performed of all patients surgically treated for CSF leaks presenting to the Section of Nasal and Sinus Disorders at the Service of ENT–Head and Neck Surgery, University Hospital Complex of Santiago de Compostela (CHUS), between 2004 and 2010. A total of 30 patients who underwent repair CSF leak by ESS. The success rate was 93.4% at the first attempt; only two patients (6.6%) required a second surgical procedure, and none of it was necessary to use a craniotomy for closure. Follow-up periods ranged from 4 months to 6 years. Conclusion Identifying the size, site, and etiology of the CSF leak remains the most important factor in the surgical success. It is generally accepted that the ESS have made procedures minimally invasive, and CSF leak is now one of its well-established indications with low morbidity and high success rate, with one restriction for fistulas of the posterior wall of the frontal sinus should be repaired in conjunction with open techniques.
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              Endoscopic management of cerebrospinal fluid rhinorrhea

              Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2017
                09 June 2017
                : 13
                : 709-715
                Affiliations
                Department of Otolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
                Author notes
                Correspondence: Qintai Yang; Peng Li, Department of Otorhinolaryngology-Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, People’s Republic of China, Tel/fax +86 20 8525 2239, Email yang.qt@ 123456163.com ; lp76@ 123456163.net
                Article
                tcrm-13-709
                10.2147/TCRM.S134537
                5472411
                © 2017 Yang et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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