1. Endoscopic management of traumatic cerebro-spinal fluid rhinorrhea
Y R Yadav, Vijay Parihar, Shailendra Ratre, Yatin Kher
Department of Neurosurgery
NSCB (Government) Medical College Jabalpur MP India
Recipient of Charak award (IMA MP state 2011)
Chairman fellowship program of one week brain and spine endoscopic training
Executive member of Neurological surgeons society of India
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2. Endoscopic management of traumatic cerebro-spinal fluid rhinorrhea
Introduction:
Communication between the intracranial subarachnoid space and the sinonasal mucosa.

3. Traumatic CSF Rhinorrhea
Accidental trauma
Surgical trauma
Early
Within 7 days
Delayed

5. S. No
MRI cisternography
CT cisternography
HR CT
Nasal endoscopy with or without fluorescene
Radionucleotide
cisternography
Advantages
Useful in active or inactive leak
Slow-flow and diffusion-weighted may have a role in active CSF leaks
FLAIR Could demonstrate herniation of meninges, brain tissue and CSF.
Useful in multiple fractures
Useful in active leak
Can differentiate contrast material from sclerotic sinus walls, dense insipissated sinus secretions and blood.
Good for bone
Can show dehiscence
When all investigation fail to show leak
When CSF leak is suspected (CSF collection not possible)
48- or 72-hour scans are possible with In111 and are useful in the detection of intermittent leaks.
Multiple site

6. S. No
MRI cisternography
CT cisternography
HR CT
Radionucleotide
cisternography
Limitations
Bone
Invasive
Problem in detecting small amount of diluted contrast from bone .
Detects the fluid poorly.
Multiple defects or fractures (which one is leaking)
Not widely available.
Unable to localize exact site ( Only as screening when diagnosis is in question)
False-positive ( 33%) as isotope can be absorbed into the circulatory system and can contaminate extracranial tissue.

7. Primary investigations:
Combined modalities of CT and MRI have a higher sensitivity and specificity.
Getting two investigations is not cost-effective.
CT cisternography in these circumstances offers an acceptable method.

8. Conservative management:
Most of the traumatic CSF rhinorrhea can be managed by observation for 7-10 days
Up to 2 to 4 weeks after trauma or operation.
Early surgery in subgroup:

9. Early surgery group (or subgroup with increased risk of meningitis
Fractures close to midline (more CSF pressure and less chances of brain plugging opening)
Fracture displacement > 1 cm,
Delayed leak or intermittent leak
Profuse leak (sphenoid sinus, petrous)
Encephalocele or a meningocele protruding through the bony defect which disallows the healing process.
Penetrating injury
Comminuted fracture

10. Operative management:
Surgery is indicated to prevent complications if conservative management fails.
3-11% risk of meningitis in first 3 weeks
10% annually
Risk more in early period

11. Advantages of endoscopic technique:
Easy access, precision and accuracy
Success rate of 90% in the first attempt
About 95-98% after a second attempt.

12. Indication for endoscopic approach
Difficult for large defect, lateral recess of frontal and sphenoid sinus especially for beginners.
Best suited for small defects in sphenoid sinus, cribriform plate, anterior and posterior ethmoid sinus

13. Head elevation Nasal cavity towards surgeon

14. Types of grafts or flaps and repair techniques:
At least 5 mm mucosa removal in all directions of defect.
Removal of any bony projections for better graft placement and graft take up.
Types of grafts or flaps and repair techniques:
Free tissue,
Vascularized flap
Composite grafts ((involves more than one type of tissue).
The Bath plug technique
The button technique

15. Overlay and underlay; relation to skull bone
Overlay technique, the graft is placed extracranially
Underlay technique, the graft is placed between dura and bone.
Intradural
Combined techniques can be used.

16. Multilayer closure for large defects
The fibrin plug to stabilize the fat graft
Layers of Gelfoam or Surgicel should separate graft from packing to avoid avulsion
Packing of gauze or balloon impregnated with an antibiotic ointment

17. Post operative care:
Bed rest for 3-5 days with head elevation.
Peri operative prophylactic antibiotics?
Avoid nose blowing, sneezing and Valsalva maneuvers.
Sneezing by open mouth
Stool softeners to avoid straining.

18. Results:
over 90% success
Careful in leveling success
Recurrences may occur very late (80 months in Gassner et al series)

19. Lumbar drain indication:
Recurrent
Persistent leaks
Associated with hydrocephalus.
Large skull defects with meningoceles.

20. Complications of Repair
Meningitis,
Chronic headache,
Pneumocephalus,
Intracranial hematomas,
Frontal lobe abscess.
Recurrence.

21. Recurrence:
Extensive skull base defects,
Multiple sites of leaks
Lateral sphenoid leaks,
Frontal sinus with extension superiorly and laterally
Raised ICP,
Diabetes mellitus
Elevated body mass index, (> 30)
Middle-aged obese female

22. Based on
Yadav YR, Parihar V, Janakiram N, Pande S, Bajaj J, Namdev H. Endoscopic management of cerebro-spinal fluid rhinorrhea. Asian journal of Neurosurgery. Ahead of print, DOI: /
Yadav YR, Parihar V, Kher Y. Complication  avoidance and its management in endoscopic neurosurgery. Neurol India 2013;61:
Yadav YR, Parihar V, Ratre S, Iqbal M. Microneurosurgical skills training. J Neurol Surg A Cent Eur Neurosurg 2015 Apr 27. [Epub ahead of print] DOI: /s

24. Thankful to my teachers

25. Thankful to my colleagues