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How will you manage a case of CFS rhinorrhoea? How do you heat a case of CFS rhinorrhoea that developed often nasal surgery? Write down different techniques of its repair/write down the surgical treatment of CSF rhinorrhoea. What are the recent advances in the treatment of rhinorrhoea?

An inter-dicisplinary team approach offers the patient the bent chance of successful outcome.

The appropriate treatment choice depends on several factors including the severally and extend of injury the aetiology and the anatomical site of the CSF leak .

The management of CSF rhinorrhoea can be divided into:

A) Medical conservative treatment

Initial trial of conservative treatment should be considered as the majority of acute traumatic fistulae will seal spontaneously.

Bed rest in “head up ” position(15-30)

Avoid : cough/sneeze/nose blowing/straining(use stool softeners)

Medication to reduce CSF fluid production rate.

  1. Acetazolamide
  2. Furesemide

Procedure to ↓ CSF Pressure:

  1. repeated removal of CFS fluid via repeat lumbar taps or an
  2. indwelling lumbar drain

Antibiotics

  • controversial whether antibiotic prophylaxis should be prescribed or not.
  • One meta analysis by Brodie states a significant reduction in the incidence of meningitis with prophylactic therapy.
  • Other do not agree.

If non-operative treatment fails after 10-14 days or if the leak recurs or chronic surgical treatment is advised.

B) Surgical treatment

Operative approaches are divided into

Intracranial (for unknown site)ExtracranialEndoscopic approach
Multiple skull base defect(>5cm)success rate 76-100%method of choice
Dandy 1st documented itsite of fistula has to be localized for thisminimal morbidity
Craniotomy through the frontal/parietal/temporal regionAsses most leaked of post wall of frontal sinussuccess rate:76-97%
External ethmoidectomy cribriform transmastoid tegment +Petrous
transsphenoidal: sphenoid coronal/ eyebrow incision to frontal sinus using osteoplastic flap
patched with facial graft
obliterated with Fat
Retains sense of smell
Nasal mucosal Flap
Free graft of nasal mucosa
composite graft with turbinate bone, conchal or septal cartilage.
Temporalis fascia,
Facia lata,
Fat

Endoscopy repair of CSF fistula

  • Reported 1st by wigand
  • CSF leak is a significant potential complication of endoscopic ethmoidectomy and immediate endoscopic repair of such leaks should be considered by any surgeon performing endoscopic nasal surgery if a CSF rhinorrhoea discovered intra-operatively.
  • Delayed onset of CSF leaks which are visible endoscopically are also amenable to endoscopic repair.
  • It is important to identify the defect accurately.The mucosa is elevate from the surrounding bone and the edges of the defect are then freshened.
  • The graft material is then placed into to defect as an underlay graft where possible. It is tucked in above the bonny skull base i.e the intracranial site. Fibrin glue can above used to seal the graft.(microfibrillar collagen)
  • Muscle or mucoperiostem(from the nasal septum) is their placed over the defect

Graft can be supported by gelfoam packing/nasal packing or BIPP. It has to be removed on 7-10 days after.

Post operatively:

  • Antibiotic coverage
  • Lumbar drain to ↓ICP ,
  • Advise not to blow nose, sneeze with their mouth open or not to sneeze to avoid any abrupt ↑ in ICP for about 1 month.

Reason for failure

– Raised ICP

Advantages of endoscopic techniques to conventional method by Mathox and Kennedy.

  1. Excellent field of vision, allowing exact localization of the teak.
  2. The ability precisely to clean mucosa from the bony defect c/0 significantly increasing in the size of the defect.
  3. Accurate positioning of the graft material  over the defect.

Leakage through frontal sinus

  • Repair via the posterior wall of frontal sinus
  • Anterior osteoplastic flap using either eyebrow /coronal incision.
  • Remove entire sinus mucosa and fill with fat.

Leakage through cribriform/plate/ ethmoid roof.

  • external ethmoidectomy approach.
  • Remove MT for exposure
  • Remove all ethmoid cell
  • septomucosal flap used at the junction of septum and olfactory slip, give the superior incision that extend AP.
  • Carry it as far as anteriorly
  • Lower incision∼1.5cm below and parallel to superior incision connects the anterior aspect of superior and inferior incision and flap is rotated 90° to cover the defect.(Posterior based flap)

Leakage through mastoid and M/E

  • Transmastoid approach
  • Use
    • Pedicled sternimastoid muscle
    • Freefat grafts(layedent)

Leakage of CSF through sphenoid sinus

  • Complete external ethmoidectomy. Use septal flap based on the inferior margin of the frontal face of the sphenoid sinus.
  • Trans- septal approach-poor visibility.
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