González SJG, Chávez VAM, Velázquez SH

Language: Spanish
References: 7
Page: 25-30
PDF size: 217.10 Kb.

ABSTRACT

Objective: To describe our experience in the handling of cerebrospinal fluid fistula on the anterior and middle skull using applied endoscopic surgical techniques.
Materials and methods: From August 2008 to December 2010, 15 patients were assisted either at the Otolaryngology and Neurosurgery Units of the Regional Hospital Dr. Valentin Gomez Farias or privately at the authors´ offices. These patients were diagnosed with cerebrospinal fluid fistula (both traumatic and nontramautic one), four of them associated with intracranial injury, other seven were spontaneous or idiopathic, two more subsequent to transsphenoidal pituitary ablation and one a peripheral effect of a tumor expansion process. Among the associated conditions meningitis was found in 2 out of 15, intrasellar arachnoidocele with fibrous dysplasia of the temporal bone in 1 out of 15, and chronic otitis media with cholesteatoma in patients with a fistula on the floor of the middle fossa. The average time of diagnosis was 42.8% in two years. Average age was 45.8, with age limits of 26-55 years and a prevalence rate for women of 1.5:1. The diagnosis was based on two points: presence of rhinorrhea and identification of the precise location of the lesion. A total of 17 operations (88%, 15 out of 17) corresponded to endoscopic closure, and 12% to intracranial one. The tissues used were classified as free or pedicled. The most used grafts were temporal fascia (in 11 out of 17 cases), the flap nasoseptal (four cases) and middle turbinate flap (4 out of 17 cases).
Results: A total of 17 operations were carried out, 15 (88%) of them used an endoscopic approach; only three cases were associated with meningocele, in two cases it was not possible to find the exact location of the fistula, even after applying fluorescein intrathecally. The average surgery time was 3-5 hours. Transsurgical complications were rare; bleeding due to handling of the mucosa was discreet. Postoperative complications included cerebrospnial fluid fistula of the middle fossa, which was treated with transmastoid approach; vertigo was present in 25%, and one patient had meningitis eight days after endoscopic surgery of the sphenoidal cerebrospinal fluid fistula.
Conclusions: The correct diagnosis of cerebrospinal fluid fistula involves optimal handling, that is, the proper choice of a surgical approach and the techniques and grafts proper for a successful closure. The endoscopic surgical approach allows the exact location through intrathecal fluorescein. The advantages given by an endoscope, meaning a better angulation and lighting, enable the surgeon to identify a locatioin accurately and in a less invasive way, thus ruling out craniotomy.

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