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Frontal Sinus Cerebrospinal Fluid Leaks Chapter 17 145 Chapter 17 Frontal Sinus Cerebrospinal 17 Fluid Leaks Bradford A. Woodworth, Rodney J. Schlosser Contents Core Messages Introduction . 143 í Identification of a CSF leak etiology; Anatomic Site . 144 accidental trauma, surgical trauma, Etiology . 147 tumors, congenital, or spontaneous; Trauma . 147 is essential for successful repair Tumors . 148 Congenital . 148 í Anatomically, frontal sinus CSF leaks are Spontaneous . 148 divided into those located adjacent to the Diagnosis . 149 frontal recess, within the frontal recess, or Surgical Technique . 149 within the frontal sinus proper Endoscopic Approaches . 149 Extracranial Repair . 150 í Pre-operative evaluation may include beta- Intracranial Repair . 151 2 transferrin, radioactive/CT cisternogram, Adjuncts and Postoperative Care . 151 high-resolution CT, MRI, or intrathecal flu- orescein and should be individualized for Conclusion . 151 the purposes of diagnosis and localization References . 151 í Frontal sinus CSF leaks adjacent to or with- in the frontal recess are typically amenable to endoscopic repair Introduction í CSF leaks affecting the posterior table Pathology of the frontal sinus represents one of the within the frontal sinus proper may require most challenging and technically demanding areas external approaches, such as frontal tre- for the sinus surgeon to reach endoscopically. Cere- phine or osteoplastic flap. Combined endo- brospinal fluid (CSF) leaks in other parts of the sino- scopic and external techniques are useful nasal cavity have been repaired with relatively high for defects extending to the frontal sinus success rates using accepted endoscopic techniques outflow tract for nearly 20 years [7], yet little has been published regarding repair of frontal sinus defects. The use of í Severely comminuted posterior table frac- 70° endoscopes and giraffe instruments allows excel- tures may require craniotomy and cranial- lent access to the frontal recess, but postoperative ization of the frontal sinus stenosis, anatomic variants, and CSF leaks associated with the posterior table can make repair of these de- fects very challenging and pushes the limits of endo- scopic repairs. Pertinent frontal sinus anatomy, etiol- ogies of CSF leaks, preoperative imaging and consid- erations, and the technique and type of repair will be discussed. 144 Bradford A.Woodworth, Rodney J. Schlosser Anatomic Site tal beak anteriorly, the orbit laterally, the attachment of the middle turbinate medially, and the face of the ethmoid bulla (if present) and ethmoid roof posteri- The complex anatomy and variability of the frontal orly. This anatomy is highly variable, and a number recess is described in great detail elsewhere in this of cells may alter this and encroach upon the frontal text, but in the most basic sense, the broadest boun- outflow tract if present, such as an agger nasi cell an- daries of the frontal recess are the internal nasofron- terolaterally or a suprabullar cell posteriorly. 17 Fig. 17.1. Coronal CT (A) and sagittal T2 weighted MRI (B) of patient with meningoencephalocele involving the posterior aspect of the frontal recess that was repaired endoscopically Frontal Sinus Cerebrospinal Fluid Leaks Chapter 17 145 CSF leaks affecting the frontal sinus can be divided ly, because the superior extent of the defect may be anatomically into three general categories: difficult to reach endoscopically and the inferi- or/posterior extension of the defect may be difficult í Those adjacent to the frontal recess to reach from an external approach (Figs. 17.1–17.3).If í Those with direct involvement of the frontal long-term frontal patency is questionable, then an recess osteoplastic flap with thorough removal of all muco- í Those located within the frontal sinus proper sa and obliteration is recommended. On the other hand, if the surgeon feels that frontal patency can be maintained, repair of the skull base defect without While most leaks are limited to one of these distinct obliteration can be performed (Fig. 17.4). sites, some defects encompass multiple anatomic ar- The final anatomic site for frontal sinus CSF leaks eas. is within the frontal sinus proper involving the poste- Skull base defects located in the anteriormost por- rior table above the isthmus of the frontal recess. The tion of the cribriform plate or the ethmoid roof just limits of endoscopic approaches continue to expand posterior to the frontal recess do not directly involve with improved equipment and experience. However, the frontal sinus or its outflow tract, but by virtue of defects located superiorly or laterally within the their close proximity, the frontal recess must be ad- frontal sinus may still require an osteoplastic flap dressed as described in the Surgical Methods section with or without obliteration. Frontal trephination of this chapter. Endoscopic repairs may cause iatro- and an endoscopic modified Lothrop procedure are genic mucoceles or frontal sinusitis if graft material, adjuvant techniques that are useful for unique cases packing, or synechiae formation obstructs the fron- (Fig. 17.5). The specific approach depends upon the tal sinus outflow tract. site and size of the defect, the equipment available, A CSF leak that directly involves the frontal recess and surgical experience. is one of the most difficult sites to approach surgical- Fig. 17.2. Endoscopic view of meningoencephalocele (from patient in Fig. 17.1) highlighted by fluorescein (A). Mucosa stripped from posterior aspect of frontal recess and septal bone graft placed into epidural space (B) 146 Bradford A.Woodworth, Rodney J. Schlosser Fig. 17.3. Overlay mucosal graft (A) placed. Sialastic stent was placed for one week. Six month postoperative view (B) demon- strates successful repair and widely patent frontal sinus 17 Fig. 17.4. Coronal (A, B) and sagittal (C) CTs demonstrate a of the defect). This required a combined endoscopic and oste- traumatic skull base defect that involved the posterior table, oplastic approach frontal recess, and ethmoid roof (arrows in C depict the extent Frontal Sinus Cerebrospinal Fluid Leaks Chapter 17 147 Surgical Goals for Frontal CSF Leaks í Goal #1 – Successful repair of the skull base defect and cessation of the CSF leak. í Goal #2 – Long-term patency of the frontal si- nus or a successful obliteration with meticu- lous removal of all mucosa within the frontal sinus. í Always be cognizant of both goals when de- ciding upon a specific surgical approach and repair for each skull base defect. Etiology The underlying cause of a CSF leak will affect the Fig. 17.4C management of the subsequent repair. CSF leaks are broadly classified into: í Traumatic (including accidental and iatrogenic trauma) í Tumor-related í Spontaneous í Congenital These etiologies influence the size and structure of the bony defect, degree and nature of the dural dis- ruption, associated intracranial pressure differential, and meningoencephalocele formation. These factors greatly influence medical and surgical treatment and help predict long-term success. Trauma Frontal sinus fractures represent approximately 5%–12% of craniofacial injuries and have a high po- tential for late mucocele formation, intracranial inju- ry, and aesthetic deformity [5, 8, 10]. Traumatic dis- ruption of the posterior table of the frontal sinus or Fig. 17.5. Isolated skull base defect in the lateral aspect of the frontal recess with a dural tear can create an obvious frontal sinus without involvement of the frontal recess. Such defects can be repaired via trephine while maintaining paten- CSF leak or present years later with meningitis, de- cy of the frontal recess layed leak, or encephalocele. Projectile injuries from 148 Bradford A.Woodworth, Rodney J. Schlosser bullets, shotgun blasts, or shrapnel can result in sig- Tumors nificant comminution of the skull base, and are more likely to involve intracranial injury. CSF leaks usually begin within 48 hours, and 95% of them manifest Anterior skull base and sinonasal tumors can create within 3 months of injury [15]. Although over 70% of frontal sinus CSF leaks directly through erosion of traumatic CSF leaks close with observation or con- the posterior table or frontal recess, or indirectly sec- servative treatment, a 29% incidence of meningitis ondary to therapeutic treatments for the tumor. Per- has been reported in long-term follow-up when sistent tumor following resection and repair will managed nonsurgically [1]. continue to erode the skull base and contribute to Conservative, nonsurgical measures are often ade- frontal sinus CSF leaks. Creating a watertight seal quate for injuries limited to the frontal recess and/or between the sinonasal and intracranial cavities after posterior table, but severe fractures may require op- tumor removal can be difficult. If the tumor is ap- erative intervention due to a high risk of subsequent proached intracranially, a pericranial flap is often mucocele formation.Here,operative intervention ad- used to create a barrier. CSF leaks may still occur due dresses both the CSF leak and the potential for future to tears in the flap that occur during elevation, devas- mucocele development,depending upon the anatom- cularization, and necrosis, or from inadequate cover- ic site of the defect. Other considerations include the age. Posterior table defects and frontal sinus floor de- overall health of the patient, associated intracranial fects (after cranialization) may still be present and or intraorbital injuries, and other skull base or facial contribute to CSF leak. Prior
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