Endoscopic Endonasal Surgical Treatment of Nasal Liquorrhea

D.N. Kapitanov, A.A. Potapov, A.S. Lopatin

(Burdenko Research Institute of Neurosurgery of the Russian Academy of Medical Science, Moscow)

The last decades are characterized by considerable widening of possibilities of endoscpic endonasal surgery. Diagnosis and treatment of nasal liquorrhea (NL) has become an inseparable part of endoscopic rhinosurgery.

There 36 cases with NL, who underwent endonasal endoscopic interventions in the Burdenko Research Institute of Neurosurgery in 1999-2000. Diagnosis was based on endoscopy of a nasal cavity, biochemical examination of glucose content in nasal discharge, CT and MRI cisternography, plain CT and MRI of the brain. According to their origin, liquor fistulas were divided into spontaneous liquorrhea (18 cases); traumatic liquorrhea (4); liquorrheas, which developed after transsphenoidal removal of pituitary adenoma (7), after removal of craniofacial tumor (3), after tumor biopsy (chordoma) from the sphenoid sinus (1), after manipulation, performed in other otorhinolaryngologic departments (2) and liquorrhea after operation on paranasal sinuses in a patient with extensive trauma of facial bones (1). Division of cases into groups was dependent on localization of liquor fistulas: the sphenoid sinus (20), anterior and posterior ethmoidal cells (8), lamina cribrosa (7), multiple defects (1). It should be mentioned, that 4 patients were operated two times. Endoscopic endonasal intervention was made in 38 cases; 2 patients were operated under control of a microscope. Defect plasty was performed with autografts in 38cases (the broad fascia, fatty tissue, mucous membrane of turbinated bones and nasal septum, cartilage of a nasal septum); TACHOKOMB was used in 1 patient. We used Tissukol (a biological fibrin-thrombin glue) in all cases (40 operations). Lumbar drainage was applied in 32 patients during endoscopic endonasal plasty of liquor fistula; usually it was removed on the fifth day after operation (a mean value). Endoscpic operation was accompanied by lumbar shunting in 4 cases. Obliteration of the sphenoid sinus resulted in sphenoiditis in 1 patient; it demanded repeated endoscopic examination.

Results: A maximum period of follow-up of 31 cases (86.8%) without liquorrhea was equal to 2.5 years; improvement of a state, which manifested itself in absence of meningitis and minimum discharge from a nose, was watched in 4 patients (8.4%). There was relapse of liquorrhea with meningitis development in 1 case (4.8%) with multiple traumatic defects of a skull base.

Conclusions:

  1. Endonasal endoscopy can be effective in plastic closure of small liquor fistulas of a skull base.
  2. Small single defects of a skull base, in particular of spontaneous or iatrogenic origin, can be regarded as an indication for endoscopic plasty.
  3. If liquor fistulas are localized in a posterior wall of a frontal sinus, as well as a temporal bone pyramid, endoscopic plasty is contraindicated.
  4. Treatment should start with shunting, if liquorrhea is accompanied by liquor hypertension.