Endoscopic management of frontal sinus CSF leaks

Abstract

Introduction: Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition.

Objective: To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach.

Methods: A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined.

Results: Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 - 41 months).

Conclusion: Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Keywords: Cerebrospinal fluid leak; Endoscopic repair; Frontal sinus; Skull base; Trephination.

Figure 1

Triplanar CT scan (A, sagittal; B, coronal; C, axial planes) of a patient with traumatic CSF leak. Multiple skull base defects (frontal sinus posterior wall and ethmoid roof) are associated with anterior sinus wall fracture.

Figure 2

Reconstruction of defect assisted by trephination.

Figure 3

A, Dural breach associated with significant posterior wall defect visible through Draf IIB sinusotomy. B, first underlay graft in multilayer reconstruction using fascia lata.

Figure 4

A, Posterior wall and frontal recess defect visible through Draf III sinusotomy. B, Reconstruction using fascia lata graft.

Figure 5

Chart corelating site of leak with surgical approach employed.

Figure 6

A, Defect located around the frontal recess. B, “Sandwich” reconstruction technique using septal cartilage and mucosa graft.