CSF Rhinorrhea: Pathophysiology, Diagnosis and Skull Base Reconstruction

Foreword
Contents
Part I
1: Skull Base Development and Anatomy
1.1 Osteology of the Three Cranial Fossae
1.2 Ventral Portion of Anterior, Middle and Posterior Cranial Fossa
1.2.1 Anterior Cranial Fossa
1.2.2 Middle Cranial Fossa
1.2.3 Posterior Cranial Fossa
1.3 Skull Base Embryology and Development
1.4 Sphenoid Bone and Sinus
1.4.1 Sphenoid Bone and Sinus Anatomy
1.4.2 Endoscopic Anatomy of the Sphenoid Sinus
References
2: Physiology of CSF
2.1 Historical Review
2.2 Nature of CSF
2.3 Volume and Pressure of CSF
2.4 Contents and Composition of CSF
2.5 Functions of CSF
2.6 Secretion of CSF
2.7 Mechanism of CSF Circulation
2.8 Absorption of CSF
2.9 The New Hypothesis of Production, Circulation, and Absorption of CSF
References
3: Pathophysiology of Skull Base Defect and CSF Leak
3.1 Epidemiology of CSF Leaks
3.2 Etiology and Pathophysiology of CSF Leaks
3.2.1 Traumatic
3.2.2 Iatrogenic
3.2.3 Congenital
3.2.4 Neoplastic
3.2.5 Spontaneous
References
Part II
4: Clinical Presentation of CSF Rhinorrhea
4.1 Introduction
4.2 Classification
4.3 History
4.4 Physical Exam
4.5 Imaging Findings
4.6 Differential Diagnosis
4.7 Conclusion
References
5: Fluid Analysis in CSF Rhinorrhea
5.1 Introduction
5.2 CSF Physiology
5.3 CSF Rhinorrhea Diagnosis
5.4 Ring Sign
5.5 Glucose Testing
5.6 Beta-2 Transferrin
5.7 Beta-Trace Protein
5.8 Others
5.9 Evidence-Based Practice
References
6: Imaging in the Work-Up of CSF Leak
6.1 Introduction
6.2 CT
6.3 MR
6.4 Traumatic (Accidental) CSF Leak
6.5 Traumatic (Post-surgery) CSF Leak
6.6 Non-traumatic (Spontaneous) CSF Leak
6.7 Non-traumatic (Pathology-Related) CSF Leak
6.8 Post-duraplasty Imaging
References
7: Role of Fluorescein in the Diagnosis of CSF Leak
7.1 Indications of Use
7.2 Fluorescein and the Informed Consent
7.3 Metabolism of Fluorescein
7.4 Intrathecal Use
7.4.1 Set-Up
7.4.2 Dose
7.4.3 Timing
7.4.4 Techniques to Improve Utilization
7.4.5 What if Injected Pre-operatively but Not Visible?
7.4.6 Interpretation of False-Negative Results
7.4.7 Endoscopic Examination and Exploration of Potential Area
7.5 Topical Fluorescein
7.6 Pediatric Age Group and Use of Fluorescein
7.7 Complications
7.8 Conclusion
References
8: Diagnostic Algorithm for Cerebrospinal Fluid Leak
8.1 Introduction
8.2 Differential Diagnosis
8.2.1 Allergic Rhinitis
8.2.2 Non-Allergic Rhinitis
8.2.3 Other Conditions Mimicking CSF Rhinorrhea
8.3 Diagnostic Approach
8.3.1 Clinical Evaluation
8.3.2 Investigations
8.4 Summary
References
Part III
9: Conservative Management of CSF Leak
9.1 Introduction
9.2 Indications of Conservative Management
9.3 Modalities of Conservative Management
9.3.1 Pharmaceutical Treatment
9.3.1.1 Antibiotics
9.3.1.2 Acetazolamide
9.3.2 Lumbar Drain
9.3.3 Immunization
9.3.3.1 Pneumococcal Vaccine
Pediatric Recommendations
Adult Recommendations
9.3.3.2 Meningococcal and Haemophilus Vaccine
9.4 Risk of Meningitis During Conservative Treatment
9.5 Indications of Surgical Intervention
References
10: Traumatic CSF Leaks
10.1 Introduction
10.2 Causes of Traumatic CSF Leak
10.2.1 Accidental Injury
10.2.2 Iatrogenic Injury
10.3 Duration of Conservative Treatment
10.3.1 Conservative Management
10.3.2 Lumbar Drain
10.3.3 Acetazolamide
10.3.4 Inappropriate for Conservative Treatment
10.4 Management of ICU Patients with Skull Base Fracture
10.5 Risk of Meningitis
10.6 Prophylactic Antibiotics
10.7 Recognition of Intraoperative Iatrogenic CSF Leak
10.7.1 Risk Assessment and Prevention
10.7.2 Identification
10.8 Timing of Surgical Intervention of Iatrogenic CSF Leak
10.8.1 Intraoperatively
10.8.2 Delayed Recognition
10.9 Special Considerations
10.9.1 CSF Otorhinorrhea
10.9.2 Positive Pressure Ventilation
References
11: Spontaneous CSF Leak
11.1 Incidence and Demographics
11.2 Pathophysiology of Spontaneous CSF Leak
11.3 Idiopathic Intracranial Hypertension (IIH)
11.4 Pathophysiology of IIH
11.5 Relationship Between Spontaneous CSF Leak and IIH
11.6 Clinical Picture
11.7 Diagnostic Approach
11.8 Imaging Studies in Spontaneous CSF Rhinorrhea
11.9 Radiologic Findings in Spontaneous CSF Rhinorrhea
11.9.1 Skull Base Osteodural Defect
11.9.2 Meningocele/Meningoencephalocele
11.9.3 Signs of Increased ICP
11.10 Treatment of Spontaneous CSF Rhinorrhea
11.11 Outcome of Surgical Repair and Postoperative Management
References
12: Multidisciplinary Approach to CSF Leak
12.1 Multidisciplinary Approach to the Cerebrospinal Fluid Leak
12.2 Otolaryngology/Head and Neck Surgery
12.3 Neurosurgery
12.4 Neurology
12.5 Ophthalmology
12.6 Bariatric Surgery
12.7 Endocrine
12.8 Sleep Medicine
12.9 Conclusion
References
Part IV
13: History of Surgical Approaches and Techniques for Skull Base Reconstruction
13.1 Historical Background
13.2 Evolution of Materials and Techniques for Skull Base Repair
13.2.1 Heterologous Materials
13.2.2 Autologous Grafts
13.2.3 Pedicled Flaps
13.2.4 Free Revascularized Flaps
13.3 Future Directions
References
14: Operative Room Set-Up and Instrumentation
14.1 Introduction
14.2 Operative Room Set-Up and Manpower
14.3 Patient Position
14.4 Image Guidance System (IGS)
14.5 Prepping and Draping
14.6 Surgical Instruments, Devices, and Biomaterials
14.6.1 Special Dissectors (Intracranial Intradural)
14.6.2 Electrocautery Devices
14.6.3 Other Instruments Used for Removal of Encephalocele
14.6.4 Special Graft Positioning Instruments/Seekers
14.6.5 Set-up of the Suction During or After Positioning of the Reconstructive Material
14.6.6 Sealants, Hemostatic Agents, and Nasal Packing
14.7 Conclusion
References
15: Role of the Anesthesiologist
15.1 Introduction
15.2 The Need for Neuro-anesthesiologists
15.3 Antibiotics Administration
15.4 Intracranial Hypertension
15.5 Obesity and OSA
15.6 Blood Pressure Management During Surgery
15.7 Valsalva Maneuver
15.8 Emergence from Anesthesia
15.9 Postoperative Care
15.10 Enhanced Recovery After Surgery (ERAS) in Neurosurgery
15.11 Conclusion
References
16: Synthetic Materials for Skull Base Reconstruction
16.1 Introduction
16.2 Xenograft
16.3 Allograft
16.4 Alloplastic
16.5 Surgical Technique
References
17: Free Autologous Grafts
17.1 Free Autologous Grafts
17.2 Types of Autologous Grafting Materials
17.3 Free Mucosal Grafts
17.4 Fat Grafts
17.5 The Fat Bath-Plug Surgical Technique
17.6 Fascia Grafts
17.7 Surgical Technique of Harvesting Fascia Lata
17.8 Bone/Cartilage Grafts
17.9 Outcomes of Various Autologous Graft Materials
17.10 Single Layer Versus Multilayer Grafts in Skull Base Repair
References
18: Local Pedicled Flaps
18.1 Introduction
18.2 Hadad-Bassagasteguy Flap
18.3 Anterior and Posterior Ethmoidal Artery Septal Flap
18.4 Septal Flip-Flap
18.5 Bipedicled Anterior Septal Flap
18.6 Posterior Pedicle Inferior Turbinate Flap
18.7 Posterior Pedicle Middle Turbinate Flap
18.8 Turbinal Flap
18.9 Anterior Pedicle Lateral Nasal Wall Flap
18.10 Surgical Technique: General Aspects
References
19: Regional Pedicled Flaps for Skull Base Reconstruction
19.1 Introduction
19.2 Trans-frontal Pericranial Flap
19.3 Temporoparietal Fascia Flap
19.4 Occipital Flap
19.5 Oliver Palatal Flap
19.6 Facial Buccinator Flap
19.7 Pedicled Buccal Fat Pad Flap
19.8 Salpingopharyngeus Flap (Dicle Flap)
19.9 Conclusions
References
20: Free Tissue Transfer for Orbital and Skull Base Reconstruction
20.1 Introduction
20.2 Endoscopic-Assisted Skull Base Free Tissue Transfer Reconstruction
20.3 Orbital Reconstruction
20.3.1 Reconstructive Approaches to Common Orbital Defects
20.3.1.1 Orbital Defect with Intact Orbital Rim
20.3.1.2 Orbital Defect Without Orbital Rim
20.3.1.3 Total Maxillectomy Defect with Orbital Exenteration
20.4 Open Skull Base Free Flap Reconstruction
20.4.1 Preparation of Recipient Vessels
20.4.2 Pedicle Length
20.4.3 Defect Considerations
20.4.4 Flap Donor Tissue Qualities
20.5 Conclusions
References
21: Repair of Cerebrospinal Fluid Leaks of the Anterior Cranial Fossa
21.1 Surgical Approaches and Exposure
21.1.1 Frontal Sinus Wall Defect
21.1.2 Ethmoid Roof and Olfactory Cleft Defect
21.2 Reconstruction Technique
21.2.1 Preparation of the Defect Site
21.2.1.1 Resection of Meningocele/Meningoencephalocele
21.2.1.2 Demucosalization
21.2.1.3 Smoothing of Bony Margins
21.2.1.4 Dura Undermining
21.2.2 Single Layer vs. Multilayer Technique
21.2.3 Underlay Vs. Overlay Technique
21.2.3.1 Underlay Technique
21.2.3.2 Overlay Technique
21.3 Use of Supporting Materials
21.4 Repair of Defects Following Skull Base Resection
References
22: Repair of Cerebrospinal Fluid Leaks of the Middle Cranial Fossa
22.1 Introduction
22.2 Repair of Skull Base After Trans-sellar Approach for Pituitary Adenomas
22.2.1 Surgical Exposure (Fig. 22.1)
22.2.2 Graded Reconstruction Based on the Severity of the Leak
22.2.2.1 No Leak: Nothing Vs Surgicel Vs Gelfoam
22.2.2.2 Small Weeping Leak: Gelfoam Vs Fat Graft with or Without Buttress with or Without Nasoseptal Flap
22.2.2.3 Large Arachnoid Tear: Fat Graft or Duraform with or Without Floor Reconstruction with or Without Nasoseptal Flap
22.2.3 When to Consider Using a Lumbar Drain: Evidences for or Against
22.2.4 Intrathecal Fluorescein
22.3 Repair of Skull Base Defect After Transtuberculum Transplanum Approach
22.3.1 Surgical Exposure (Fig. 22.1, Video 22.1)
22.3.2 Dealing with Mucosa and Bone Around Defect
22.3.3 Reconstruction Technique
22.3.3.1 Inlay, Onlay Multilayer Closure with NS Flap
22.3.3.2 Button Closure with NS Flap
22.3.3.3 Gasket Seal Closure with NS Flap
22.3.3.4 Use of Fat
22.3.4 Evidence for and Against Use of LD
22.3.5 Use of Fluorescein
22.4 Endoscopic Repair of Sternberg’s Canal and Other Defects of the Lateral Recess of the Sphenoid Sinus
22.4.1 Debate About Whether It Is Really a “Sternberg Canal” Leak
22.4.2 Surgical Exposure: Transpterygoid Approach (Fig. 22.2, Video 22.2)
22.4.3 Dealing with Mucosa and Bone Around Defect
22.4.4 Reconstruction Technique
22.4.5 Correction of CSF Leaks in the Lateral Recess of the Sphenoid Sinus: Current Results
22.5 Limitations and Surgical Challenges of Sellar, Suprasellar, and Lateral Sphenoid CSF Leak Repair
22.6 Conclusions
References
23: Repair of Cerebrospinal Fluid Leaks of the Posterior Cranial Fossa
23.1 Introduction
23.2 CSF Leak Repair: Transclival Approach
23.2.1 Upper Transclival Approach
23.2.2 Middle/Lower Transclival Approach
23.3 CSF Leak Repair: Transodontoid Approach
23.4 Limitations and Surgical Challenges
23.5 Postoperative Care
23.6 Management of Postoperative CSF Leak
23.7 Literature Review
23.8 Conclusion
References
24: The Proper Use of Reconstructive Material
24.1 Introduction
24.2 Materials
24.2.1 Free Autografts
24.2.2 Synthetic Dural Grafts
24.2.3 Vascularised Flaps
24.2.4 Absorbable Sealants and Glues
24.2.5 Reconstructive Factors
24.3 Size and Site
24.4 Pathology
24.5 Conclusion
References
25: External Approaches for Skull Base Reconstruction
25.1 Introduction
25.2 Systematic Zone-Based Approach
25.2.1 Anterior Skull Base (Zone I)
25.2.2 Middle Fossa Skull Base Defects (Zone II)
25.2.3 Posterior Fossa Defects and Posterior Petrous Bone (Zone III)
25.3 General Concepts in External Skull Base Reconstruction
25.3.1 Free Grafts
25.3.2 Local and Regional Flaps
25.3.3 Microvascular Free Flaps
25.4 External Surgical Approaches for Skull Base Reconstruction
25.4.1 Subfrontal and Transbasal Approaches
25.4.1.1 Pericranial Flap
25.4.2 Temporalis Muscle Flap
25.4.2.1 Temporalis Muscle Flap
25.4.3 Transmastoid
25.5 Combined Endoscopic Assist External Approaches
25.5.1 Temporoparietal Flap Combined with Transpterygoid Approach
25.5.1.1 Temporoparietal Flap
25.5.2 Minimally Invasive Endoscopic Pericranial Flap [24]
25.6 Microvascular Free Flaps in Open Approaches
25.7 Limitations and Complications of the External Approaches
References
Part V
26: Postoperative Instructions
26.1 Introduction
26.2 Packing of the Surgical Field and Duration of Packing
26.3 General Postoperative Observation and Care
26.4 Imaging (CT Brain) in Early Post-op Period
26.5 Bed Rest
26.6 Head Elevation
26.7 Deep Venous Thrombosis Prophylaxis
26.8 Hospital Stay
26.9 Diet Restrictions
26.10 Drug Therapy
26.11 Precautions: Blowing the Nose, Lifting Heavy Objects, Leaning Forward, Sneezing, Coughing, Vomiting, Constipation, Physical Activity
26.12 OSA Patients and CPAP
26.13 Air Travel
26.14 Sports and Heavy Duty Jobs
26.15 Time Interval to Return to Normal Activity
26.16 Postoperative Nasal Physiology and Local Nasal Care
26.17 Postoperative Adjuvant Radiotherapy in Malignant Tumors
References
27: Surgical Complications of Skull Base Reconstruction
27.1 Prevention of Complications
27.2 Early Complications
27.2.1 Injury of Ethmoidal Arteries
27.2.2 Cranial Nerve Morbidity
27.2.3 Mucosal Flap Necrosis
27.2.4 Surgical Site Infection
27.2.5 Injury of Descending Palatine Nerve and Vidian Nerve During Access to Stemberg’s Canal Defect
27.2.6 Early Complications of Postoperative CSF Leaks
27.2.6.1 Chemical or Infectious Meningitis/Encephalitis
27.2.6.2 Pneumocephalus
27.2.6.3 Hydrocephalus
27.3 Late Complications
27.3.1 Brain Herniation
27.3.2 Anosmia/Hyposmia
27.3.3 Septal Perforation After Graft or Flap
27.3.4 Donor Site Morbidity
27.3.4.1 Anterolateral Thigh
27.3.4.2 Temporoparietal Flap
27.3.4.3 Pericranial Flap
27.3.5 Paranasal Sinus Mucocele
References
28: Failure of CSF Leak Repair
28.1 Introduction
28.2 Patient Factors
28.2.1 BMI
28.2.2 Elevated ICP
28.2.3 Other Factors
28.3 Etiology
28.3.1 Iatrogenic Leaks
28.3.2 Non-Iatrogenic Traumatic Leaks
28.3.3 Spontaneous Leaks
28.4 Site of CSF Leak
28.5 Technique
28.6 Adjunctive Management
28.7 Recurrence
28.8 Conclusion
References
29: Role of Lumbar Drain in CSF Leak Management
29.1 Introduction
29.2 Concept and Role of Lumbar Drain in CSF Leak
29.3 The Use of Lumbar Drain in CSF Leak
29.4 Indications for Lumbar Drain Placement in Skull Base Surgery
29.5 Contraindications of LD in Skull Base Surgery
29.6 LD Procedure, Precautions and Patient’s Instructions
29.6.1 Equipment (Fig. 29.3a)
29.6.2 Procedure
29.6.3 Management
29.6.4 Precautions
29.6.5 Removal
29.7 Complications of LD
References
30: Long-Term Follow-Up Strategy
30.1 Introduction
30.2 Intraoperative Considerations
30.3 Immediate Postoperative Care and ICU Management
30.4 Early Postoperative Care
30.5 Special Considerations in Patients with Spontaneous CSF Rhinorrhea
30.6 Frequency and Length of Follow-Up After CSF Leak Repair
30.7 Methods of Surveillance
30.7.1 Clinically
30.7.2 Postoperative Imaging
30.7.3 Neuro-Ophthalmological Evaluation
30.7.4 Quality of Life (QOL) Assessment
30.7.5 Other Methods of Surveillance
References
31: Cerebrospinal Fluid Rhinorrhea in Children
31.1 Introduction to Pediatric Cerebrospinal Fluid Leaks
31.2 Etiology and Pathophysiology
31.2.1 Congenital Etiology
31.2.2 Traumatic Etiology
31.3 Diagnostic Work-Up and Localization of CSF Leaks
31.4 Management of CSF Leaks in Children
31.4.1 Conservative Management
31.4.2 Surgical Treatment
31.4.3 Surgical Challenges in Pediatric CSF Leakage
31.4.4 Surgical Approaches: Intracranial Vs Endoscopic Endonasal
31.4.5 The Endoscopic Endonasal Approach
31.4.6 Materials Used for Repair
31.4.7 Timing of Repair of Congenital Meningoencephaloceles
31.4.8 Postoperative Management
31.5 Summary
References
32: Outcomes of Skull Base Reconstruction
32.1 Introduction
32.2 General Success Rates: Endoscopic Vs. Open Approaches
32.3 Repair Techniques
32.3.1 CSF Leak Flow Rate
32.3.2 Leak Location
32.3.3 Dural Defect Size
32.4 Inpatient Vs. Outpatient Repair of CSF Leaks
32.5 Prognostic Factors for Successful Repair
32.6 Long-Term Outcomes
32.7 Summary
References
33: Abnormal Presentation of CSF Leak
33.1 Unusual Presentation
33.2 Clival Lesion
33.3 Optic Nerve
33.4 Eustachian Tube Leakage of the Middle Skull Base
33.5 Distant Pseudomeningoceles of the Ventral Skull Base
33.6 Systemic Disease
33.7 Nonsurgical Iatrogenic-Induced CSF Leak
References
34: Management of Idiopathic Intracranial Hypertension
34.1 Definition
34.2 Terminology
34.3 Epidemiology
34.4 Associations
34.5 Pathogenesis
34.6 Diagnosis
34.7 Symptoms
34.8 Signs
34.9 Imaging
34.10 Diagnostic Lumbar Puncture
34.11 Management
34.12 Acetazolamide
34.13 Topiramate
34.14 Steroids
34.15 Other Medications
34.16 Therapeutic Lumbar Puncture
34.17 Surgery
34.18 Cranial Decompression
34.19 Optic Nerve Sheath Fenestration
34.20 Shunt Surgery
34.21 Lumbo-Peritoneal Shunts
34.22 Ventriculo-Peritoneal Shunts
34.23 Endoscopic Repair
34.24 Venous Sinus Stenting
34.25 Weight Loss
34.26 Conclusion
References
35: Olfaction and CSF Leak
35.1 Introduction
35.1.1 Cerebrospinal Fluid Rhinorrhoea and Olfaction
35.1.2 Head Trauma, CSF, and Olfaction
35.1.3 Iatrogenic
35.1.4 Idiopathic Intracranial Hypertension (IIH)
35.1.5 Tumours
35.2 Preventative Management
35.2.1 Olfactory Assessment
35.2.2 Imaging
35.2.3 Technique and Sequelae
35.2.3.1 Direct Trauma and Reconstruction
35.2.3.2 Inflammation and Obstruction
35.2.3.3 Evidence for Prognosis of Postoperative Olfactory Function
References
Part VI
36: CSF Rhinorrhea and Infection
36.1 Introduction
36.2 Pathophysiology
36.3 Risk Factors
36.3.1 CSF Leakage
36.3.2 Duration of the CSF Leakage
36.3.3 Gender, Type of Surgery, Complex Tumors, Presence of an External Ventricular Drain or Shunt
36.3.4 Lumbar Drain Duration
36.3.5 Reoperation
36.3.6 Increased BMI
36.3.7 Pneumocephalus and Diaphragmatic Defects
36.4 Epidemiology and Incidence of Infection in CSF Rhinorrhea
36.4.1 Incidence of Infection in Spontaneous CSF Rhinorrhea
36.4.2 Incidence and Type of Infection in Posttraumatic CSF Rhinorrhea
36.4.2.1 Accidental Trauma
Meningitis
Recurrent Meningitis
Penetrating Injury
Iatrogenic Trauma
36.4.2.2 Types of Surgery
Endonasal Transsphenoidal Surgery
Endonasal Transsphenoidal Surgery vs Sublabial Transsphenoidal Surgery
Endoscopic Endonasal (EE) Versus Microscopic Transsphenoidal (MT) Versus Open Transcranial (OT) Resection of Craniopharyngiomas
36.5 Microbiology
36.5.1 Community-Acquired Pathogens
36.5.2 Nosocomial-Acquired Pathogens
36.6 Diagnosis of CNS Infections in Patient with CSF Leakage
36.6.1 Clinical Presentation
36.6.2 Physical Examination
36.6.3 Laboratory
36.6.3.1 Routine Laboratory
36.6.3.2 Lumbar Puncture and CSF Analysis
36.6.3.3 Specific CSF Diagnostic Tests
CSF Color
WBC Count
CSF Glucose Concentration
CSF Protein Concentration
CSF Cultures
36.6.3.4 Gram Stain
Latex Agglutination
PCR
36.6.4 Imaging Studies
36.7 Medical Management of CNS Infections
36.7.1 Community-Acquired Meningitis
36.7.1.1 Duration of Therapy
36.7.1.2 Adjunctive Dexamethasone Therapy
36.7.1.3 Outpatient Antimicrobial Therapy in Patients with Bacterial Meningitis
36.7.2 Nosocomial Meningitis
36.7.2.1 Duration of Therapy
36.7.3 Repeated Lumbar Puncture
36.8 Antibiotic Prophylaxis
36.8.1 In Patient with Preoperative CSF Leakage
36.8.2 In Patient with Intra and Post- operative CSF Leakage
36.9 Role of Vaccination in CSF Rhinorrhea
36.9.1 Pneumococcal Vaccination
References
37: Evidence-Based Medicine in Cerebrospinal Fluid Leak and Skull Base Reconstruction
37.1 Evidence-Based Diagnosis of Cerebrospinal Fluid Rhinorrhea
37.1.1 Diagnosis
37.1.1.1 Ring Sign
37.1.1.2 Glucose Test
37.1.1.3 Beta-2 Transferrin
37.1.1.4 Beta Trace Protein
37.1.1.5 Radionuclide Cisternography
37.1.1.6 Other Radiologic Testing
37.1.2 Localization
37.1.2.1 Radionuclide Cisternography
37.1.2.2 Computed Tomography Scanning
37.1.2.3 Magnetic Resonance Imaging
37.1.2.4 Combination Studies
37.1.3 Intrathecal Fluorescein
37.2 Evidence-Based Management of CSF Rhinorrhea and Skull Base Reconstruction
37.2.1 Spontaneous CSF Rhinorrhea
37.2.1.1 Weight Loss
37.2.1.2 Acetazolamide and Shunt
37.2.2 Lumbar Drainage in the Management of CSF Rhinorrhea
37.2.2.1 High-Flow Leaks
37.2.2.2 Low-Flow Leaks
37.2.3 Vascularized Flap Versus Free Graft
37.2.3.1 Large Versus Small Skull Base Defects
37.2.4 Non-iatrogenic Traumatic CSF Rhinorrhea
37.2.4.1 Antibiotics
37.2.4.2 Lumbar Drain
37.2.5 Antibiotics in Surgical Defects
References
38: Quality of Life in CSF Leak
38.1 Introduction
38.2 Measuring Quality of Life
38.3 Relevant Available QOL Instruments in CSF Rhinorrhea
38.3.1 Generic Instruments
38.3.2 Disease-Specific Instruments
38.4 Quality of Life in Endoscopic Endonasal Surgery Techniques in CSF Rhinorrhea
38.5 Conclusions
References
39: Surgical Competencies and Simulation Models in CSF Leak Repair
39.1 Introduction
39.2 The CSF Leak Simulation Model
39.2.1 Settings
39.2.2 Steps
39.2.3 Validation
39.2.4 Limitations
39.3 Other Models
References
40: Patient Advocacy and Medicolegal Issues In CSF Rhinorrhea
40.1 Informed Consent
40.2 Intraoperative Tools
40.3 Communication After Iatrogenic Leak
40.4 Legal Considerations
40.4.1 Logistics
40.4.2 Financial Considerations
40.4.3 Legal Outcomes by Type of Surgery
40.5 Conclusion
References