Chapter( 6): Updates In Frontal Sinus Surgery

Endoscopic Management of Frontal Sinus CSF Leaks

Pathology of the frontal sinus represents one of the most challenging areas for the sinus surgeon to reach endoscopically. The use of 70 endoscopes and giraffe instruments allows excellent access to the frontal recess !ut postoperati"e stenosis anatomic "ariants and #SF lea$s associated with the posterior ta!le can ma$e repair of these defects "ery challenging and pushes the limits of endoscopic repairs ( Yessenow and McCa e!"#$#) % &tiology:
The underlying cause of a #SF lea$ will affect the management of the su!se%uent repair. #SF lea$s are !roadly classified into& Spontaneous. Traumatic 'including accidental and iatrogenic trauma(. Tumor)related. #ongenital.

Spontaneous:
Patients with no other recogni*a!le etiology for their #SF lea$ are deemed spontaneous. Most fre%uently these lea$s occur in o!ese middle)age females who demonstrate ele"ated intracranial pressure '+#P(. +n the frontal sinus spontaneous lea$s rarely occur through the posterior ta!le itself and are more li$ely to occur at wea$er sites of the s$ull !ase such as the ethmoid roof or anterior cri!riform plate immediately ad,acent to the frontal recess. They are usually associated with meningoencephalocele in 70(Castelnuo'o et al!())$) .

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Chapter( 6): Updates In Frontal Sinus Surgery

*rau+a:
Frontal sinus fractures represent approximately 5%-2% of craniofacial in,uries and ha"e a high potential for late mucocele formation intracranial in,ury and aesthetic deformity. Traumatic disruption of the posterior ta!le of the frontal sinus or frontal recess with a dural tear can create an o!"ious #SF lea$ or present years later with meningitis delayed lea$ or encephalocele. #SF lea$s usually !egin within ./ hours and 01- of them manifest within 2 months of in,ury ( ,er ino et al!())")% #onser"ati"e nonsurgical measures are often ade%uate for in,uries limited to the frontal recess and3or posterior ta!le !ut se"ere fractures may re%uire operati"e inter"ention due to a high ris$ of su!se%uent mucocele formation. 4ere operati"e inter"ention addresses !oth the #SF lea$ and the potential for future mucocele de"elopment depending upon the anatomic site of the defect ( McCor+ack et al!"##))%

*u+ors related:
5nterior s$ull !ase and sinonasal tumors can create frontal sinus #SF lea$s directly through erosion of the posterior ta!le or frontal recess or indirectly secondary to therapeutic treatments for the tumor ( -oodworth and Schlosser!()).)%

Congenital:
Since the frontal sinus is not present at !irth congenital lea$s of the frontal sinus proper do not exist. 4owe"er #SF lea$s may de"elop within or ad,acent to the frontal recess and congenital defects often arise from the foramen cecum (Castelnuo'o et al!())$)%
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Chapter( 6): Updates In Frontal Sinus Surgery

Esta!lishing the diagnosis and identifying the location of a #SF lea$ in a patient with intermittent clear nasal drainage and no history of head trauma can !e difficult. Pre)operati"e tests should !e !ased upon the clinical picture and the precise information needed. +n addition the in"asi"eness of the test and ris$s to the patient should !e considered. The reported sensiti"ity and specificity of any test should !e interpreted with caution as these statistics are highly dependent upon the si*e of the defect flow rate of the lea$ and the indi"idual interpreting the test ( /i+ et al!())")% 0nato+ic Site: #SF lea$s affecting the frontal sinus can !e di"ided anatomically into three general categories :( /i+ et al!())")% 6. Those ad,acent to the frontal recess& S$ull !ase defects located in the anteriormost portion of the cri!riform plate or the ethmoid roof ,ust posterior to the frontal recess do not directly in"ol"e the frontal sinus or its outflow tract !ut !y "irtue of their close proximity the frontal recess must !e addressed. Endoscopic repairs may cause iatrogenic mucoceles or frontal sinusitis if graft material pac$ing or synechiae formation o!structs the frontal sinus outflow tract (Castelnuo'o et al!())$) . 7. Those with direct in"ol"ement of the frontal recess 5 #SF lea$ that directly in"ol"es the frontal recess is one of the most difficult sites to approach surgically !ecause the superior extent of the defect may !e difficult to reach endoscopically and the inferior posterior extension of the defect may !e difficult to reach from an external approach ( -oodworth and Schlosser !()).)%

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Chapter( 6): Updates In Frontal Sinus Surgery

2. Those located within the frontal sinus proper #SF lea$s are within the frontal sinus proper in"ol"ing the posterior ta!le a!o"e the isthmus of the frontal recess. The limits of endoscopic approaches continue to expand with impro"ed e%uipment and experience. 4owe"er defects located superiorly or laterally within the frontal sinus may still re%uire an osteoplastic flap with or without o!literation. Frontal trephination and an endoscopic modified 8othrop procedure are ad,u"ant techni%ues that are useful for uni%ue cases ( -oodworth ()).)% and Schlosser !

Surgical ,oals 1or Frontal CSF Leaks: 9oal 6& Successful repair of the s$ull !ase defect and cessation of the #SF lea$. 9oal 7& 8ong)term patency of the frontal sinus *echni2ues 1or 3iagnosing and Locali4ing CSF Leaks: 5eta6( *rans1errin(Skedros et al!"##7) .
5d"antages& 5ccurate nonin"asi"e :isad"antages& ;on)locali*ing

8igh6resolution coronal and a9ial C* scan

5d"antages& Excellent !ony detail :isad"antages& +na!ility to distinguish #SF from other

soft tissue< !ony dehiscences may !e present without a lea$ :adioacti'e cisternogra+s:
5d"antages& 8ocali*es side of the lea$ identifies low

"olume orintermittent lea$s

:isad"antages& 8ocali*ation imprecise
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Chapter( 6): Updates In Frontal Sinus Surgery

C* cisternogra+s:
5d"antages& #ontrast may pool within frontal sinus< good

!ony detail
:isad"antages& +n"asi"e may not detect intermittent lea$s

M:I cisternography:
5d"antages& Excellent soft tissue '#SF3!rain "s.

secretions( detail nonin"asi"e

:isad"antage& Poor !ony detail Intrathecal 1luorescein: 5d"antages& Precise locali*ation !lue light filter can

impro"e sensiti"ity
:isad"antages& +n"asi"e< s$ull !ase exposure re%uired

for precision locali*ation (Lioyd et al!())$)% Surgical *echni2ue: :efects located inferiorly in the posterior ta!le within the frontal recess itself or those immediately ad,acent to the frontal recess are generally amena!le to endoscopic repair intrac ranial procedures (Schlosser and 5olger !())()% + n,ection intrathecal fluorescein '0.6 cc of 60- fluorescein
in 60 cc of #SF in,ected o"er 60 minutes( and place a lum!ar drain. This aids with intraoperati"e locali*ation of the defect !lue light can !e helpful for easier identification. To o!tain ade%uate exposure a total ethmoidectomy maxillary antrostomy and frontal sinusotomy as well as partial middle tur!inectomies or an endoscopic modified 8othrop may !e indicated ( ;lacantonakis et al!())<) .

there!y

minimi*ing the potential complications of other extracranial or

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Chapter( 6): Updates In Frontal Sinus Surgery

Fig.=.27& surgical repair of a frontal sinus #SF lea$. '5( 5 large encephalocele fills the frontal sinus. ;ote fluorescein #SF flowing out of the f s. '>( The encephalocele is remo"ed and the dimensions of the defect and distance from the anterior ethmoid roof are measured. '#( 5 nasoseptal flap is placed onto the posterior ta!le after underlay repair graft and Surgisus. ':( Postoperati"e "iew of well)healed nasoseptal flap repair on the posterior ta!le with a widely patent frontal sinus at 6 year(8adad et al!())6)% 5n inlay or onlay free tissue graft may !e used to patch the site of in,ury.Fascia lata temporalis muscle a!dominal fat septal or middle tur!inate mucosa or composite grafts Epidural inlay graft: the dura is ele"ated around the edges of the defect using a small ele"ator and the graft is inserted !etween the dura and the !one of the s$ull !ase. Subdural inlay graft: the dura may !e separated from the !rain and the inlay graft may !e placed in the su!dural space. Onlay graft : ?hen an inlay graft is not possi!le due to technical difficulties or !ecause the lea$ in"ol"es a linear fracture that does not expose the dural defect or !ecause dissection of the duramay ris$ neuro"ascular structures the graft is placed as an onlay o"er the defect outside the cranial ca"ity (;urkey et al!())#)%
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periosteum

and

perichondrium are suita!le grafting tissues (Meco et al!())$)%

Chapter( 6): Updates In Frontal Sinus Surgery

Bath Plug graft:

Free muscle or fat grafts can also !e used as a dum!!ell graft. Fi!rin glue platelet rich serum or other !iologic glue may !e used to increase the adhesi"eness of the muscle or fascia graft. The graft is supported in place with layers of 9elfoam followed !y a sponge pac$ing or !acitracin)impregnated gau*e. 9elfoam pre"ent adherence of the pac$ing to the graft thus pre"enting accidental a"ulsion of the graft when the pac$ing is remo"ed 2 to 7 days after the surgery ( 5anks et al!())#)%

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Chapter( 6): Updates In Frontal Sinus Surgery

@sing 0 20 and 70 nasal endoscopes s$ull !ase defect is identified 5 nasoseptal flap !ased on the posterior septal artery was used in the ma,ority of cases.6= Free grafts were used when the septum was in"ol"ed with tumor and nasoseptal flap reconstruction of frontal sinus defects was not attempted until mid)700/ (Martin et al!())$)% The flap is created from an anterior hemitransfixion incision to maximi*e length. The inferior and superior incisions are typically completed using radiofre%uency co!latio technology The flap is raised with a suction ele"ator and displaced into nasopharynx. For reconstruction in"ol"ing the cri!riform plate and medial posterior ta!le the flap is draped "ertically from the medial aspect of the choana (Fortes et al!())<)% ?hen defects are laterally)!ased the mucosa of the medial or!ital wall is remo"ed and the flap is rotated and positioned along the or!ital wall and o"er the defect in the frontal sinus. 5 :raf +++ procedure 'ie !ilateral resection of the frontal sinus floor( was performed when necessary for s$ull)!ase resection and impro"ed access to the posterior ta!le (=irgin et al!()"")% The s$ull)!ase defect was metic meticulously prepared following tumor3encephalocele remo"al. #losure of the defect in"ol"ed placement of a "ariety of grafts (8adad et al!())6)% the graft site is prepared !y remo"ing a cuff of normal mucosa around the !ony defect. This not only pro"ides an area of adherence for the graft !ut also contri!utes to osteoneogenesis and osteitic !one formation. This thic$ens the !one around the defect and aids !ony closure if a !one graft is used !etween the graft and recipient !ed ( 5olger and McLaughlin!())7)%
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Chapter( 6): Updates In Frontal Sinus Surgery

The choice of grafts is often of personal preference !ut may include alone or in com!ination the following& !one cartilage mucosa fascia and alloplastic materials These grafts are typically free grafts rather than pedicled. >one 'or cartilage in select cases( grafts for large s$ull !ase defects can pro"ide structural support for herniating dura or !rain that may displace the o"erlay fascia or mucosa graft. >one grafts are also useful in smaller defects when the patient has a spontaneous lea$ and ele"ated intracranial pressures. This ele"ated pressure contri!utes to disruption of the soft tissue graft and is responsi!le for the higher failure rates in this category. Mastoid cortex parietal cortex septal and tur!inate !one are all accepta!le !one grafts. +f a mucosal graft is used septal or tur!inate !one may !e a more suita!le option (Schick et al!())")%

Aegardless of the choice of graft the !one is shaped to match the !ony defect and placed in an underlay fashion in the epidural space. #are must !e ta$en to a"oid enlargement of the existing !ony defect or entrapment of mucosa in the epidural space that may lead to an intracranial mucocele. 5 fascia or mucosal graft is then placed in an o"erlay fashion o"er the s$ull !ase defect and supported with gelfoam and intranasal pac$s. ;on a!sor!a!le pac$ing is typically remo"ed 1)7 days postoperati"ely ( 5anks et
al!())#)%

E"en with meticulous dissection and wide exposure of the frontal recess the potential for o!struction of the frontal recess !y grafts or pac$ing material is high. To a"oid this a soft silastic
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Chapter( 6): Updates In Frontal Sinus Surgery

frontal stent for can !e placed one wee$. #areful de!ridement and cleaning e"ery wee$ for se"eral wee$s will lessen the incidence of scarring and ma$e future sur"eillance easier ( 5anks et al!())#)%

0d>uncts and postoperati'e care:

8um!ar drains are a useful ad,unct in the management of frontal sinus #SF lea$s. They allow lowering ele"ated intracranial pressure in patients with a spontaneous etiology. These patients will ha"e increased pressure postoperati"ely due to o"erproduction against a closed defect. 5 lum!ar drain is used in selected patients who will ha"e ele"ated intracranial pressure postoperati"ely and left in place for 7)2 days ( Leng et al!())$)%
5ceta*olamide is a diuretic that can !e a useful ad,unct in patients with ele"ated #SF pressures. +t can decrease #SF production up to ./- ( Carrion et al!())") .

Patients are instructed to a"oid hea"y lifting nose !lowing and excessi"e straining. Patients are also prescri!ed pain medications and stool softeners ' /ountakis !()).)%

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