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4/25/2014
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxillofacial Trauma
Eric W. Wang, MD
Center for Cranial Base SurgeryUniversity of Pittsburgh Medical Center
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Disclosure
• None
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Learning Objectives
• Review the anatomy and common fractures of the maxillofacial skeleton
• Understand the indications for intervention in bony maxillofacial trauma
• Overview the surgical approaches to the maxillofacial skeleton
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxillofacial Trauma
• Mandible
• Maxilla
• Zygomaticomaxillarycomplex
• Orbital floor
• Nasal Bone
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Initial Evaluation
• ABC’s
– Possible sublingual hematoma
• Cervical spine and other associated injuries
• Identify the mechanism of injury
• PMH: bony growth abnormalities, osteoporosis
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Key Questions
1. Do you see “double?”
2. Are there any areas of numbness on your face?
3. Does your bite feel “normal?”
4. Which areas of your face hurt?
5. Does it hurt when you open your mouth?
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination
1. Soft tissues
2. Nerves
3. Facial Skeleton
– Inspection
– Palpation
4. Dentition
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Work‐Up
• Maxillofacial CT without contrast
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Mandible Anatomy
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Anatomy
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Mandible Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: Mandible Fracture
• Motor Vehicle Accident
• Altercation
• Work related accidents
• Fall
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination
• External skin lacerations, hematoma
• Oral mucosal lacerations, hematoma
• Deviation of the mouth
• Occlusion
• Palpate contour, TMJ
• Assess mobility
• Lip/Chin Numbness
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Occlusion: Angle ClassificationThe mesiobuccal cusp of the upper first molar should align
with the buccal groove of the mandibular first molar
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
Panorex CT maxillofacial s contrast
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: Mandible
• Surgical Goal: To maintain stability– Restoration of occlusion and facial contour
– Prevent infection, osteomyelitis
• Malocclusion
• Open Fractures
• Coronoid fracture: No intervention needed
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Closed Treatment: MMF
• Unilateral condyle fracture
• Severely comminuted fractures
• Children
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF Mandible
• Unfavorable fractures
• Fractures open to skin
• Multiple facial fractures
• Nonunion
• Malunion
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Approach: Intraoral
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Approach: External Risdon Incision
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
External Access
Risdon Incision Retromandibular incision
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF Mandible: 2 Point Fixation
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Two Point Fixation: Plate and Arch Bar
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Mandible Fracture
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Post‐Operative CT
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Gunshot wound to the Mandible
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF Mandible
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Primary Closure
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Post‐Operative CT Reconstruction
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxilla Anatomy
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Maxilla: Le Fort Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Le Fort Fractures
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: Maxilla Fracture
• Motor Vehicle Accident
• ATV Accidents
• Altercation: Usually with a weapon
• Work related accidents
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination: Le Fort Fx
• Oral mucosal lacerations, hematoma
• Midface widening
• Occlusion
• Midface/Palate mobility
• Cheek or teeth numbness
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Le Fort I Fracture Patterns
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: Maxilla
• Surgical Goal: To maintain stability
– Restoration of occlusion and facial contour
– Prevent infection, osteomyelitis
• Prevent malocclusion and palate mobility
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ORIF LeFort I: Intraoral Approach
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Zygomaticomaxillary Complex (ZMC) Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC Fractures
Four Fractures of ZMC
1. Zygomatic Frontal
2. Inferior Orbital Rim
3. Zygomatic Arch
4. Lateral Maxillary Buttress
Previously misnamed Tripod Fracture
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: ZMC Fracture
• Altercation: Usually with a weapon
• Falls
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination: ZMC Fx
• Trismus
• Facial Symmetry
• Cheek numbness
• Palpate orbital rims and zygomatic arch
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Zygomatic Arch Fracture
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: ZMC
• Surgical Goal:
– Restoration of facial contour and symmetry
– Trismus
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC: Multiple Approaches and Plating
Options
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC: Multiple Approaches and Plating Options
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
ZMC: ORIF Repair
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Orbital Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Orbital Anatomy
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: Orbital Fracture
• Falls
• Altercation
• Motor Vehicle accident
• Sports related accident
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination: Orbital Fx
• Decreased Eye Motion
– Entrapment
• Globe Injury
• Cheek numbness
• Visual Acuity
• Forced Duction Test
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Early Therapy
• Avoid Nose blowing
• ? Antibiotic Therapy
• Ice to face, Raise head of bed
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: Orbital Fracture
• Surgical Goal: – Prevent enophthalmos– Treat entrapment
• Orbital Floor Fracture– > 50% of the orbital floor with herniated orbital contents– Diplopia and Entrapment
• Medial Orbital Fracture– Repair in conjunction with orbital floor fracture if change in
orbital volume
• Superior and Lateral Orbital fractures– Rarely require repair
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Orbital Floor Approaches
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Orbital Floor Repair
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Nasal Bone Fractures
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common etiologies: Nasal Fracture
• Accidents
• Sports
• Altercation
• Falls
• Motor Vehicle Accident
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Examination: Nasal Fx
• External Changes to the nose
• Septal Deviation
• Nasal obstruction
• Epistaxis
• Rhinorrhea
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Septal Hematoma
Emergent Incision and Drainage to Prevent Septal Perforation
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Imaging
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Surgical Indications: Nasal bone Fx
• Surgical Goal:
– Restoration of nasal appearance
– Nasal congestion
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Closed Reduction
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Cerebrospinal Fluid Leaks
Eric W. Wang, MD
Center for Cranial Base SurgeryUniversity of Pittsburgh Medical Center
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Learning Objectives
• Review the etiology of cerebrospinal fluid (CSF) rhinorrhea
• Learn the evaluation and work‐up for CSF leaks
• Understand the complications associated with CSF leaks
• Overview the management of CSF leaks
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Congenital Encephalocele
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Historical Classification of CSF leaks
• Traumatic– Accidental
– Surgical
• Non‐traumatic– High pressure
• Tumors
– Normal pressure• Tumors
• Congenital
• Spontaneous
• Accidental– Motor vehicle accident
– Motorcycle/ATV
• Surgical– Endoscopic sinus surgery
– Neurosurgery
– Planned skull base surgery
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Traumatic CSF Leak
• 18 year old male s/p ATV accident
• Continuous rhinorrhea and headache
• Cognitive changes
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Post‐FESS CSF Leak
• 57 yo male s/p FESS
• 3 days of severe headache
• Meningitis
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Evaluation and Work‐Up
• No age demographic
• History of Surgery or Trauma
• Confirm clear rhinorrhea with beta‐2 transferrin
• High resolution CT of the skull base
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Management
• Accidental– Lumbar drain, bedrest, stool softeners for 7 days
– If persists, surgical repair is indicated• Debridement of bone fragments
• Free graft or vascularized repair
• Post‐surgical– Early repair of CSF leak to prevent meningitis
– Free graft or vascularized flap repair
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Post‐FESS CSF Leak
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Historical Classification of CSF leaks
• Traumatic– Accidental
– Surgical
• Non‐traumatic– High pressure
• Tumors
– Normal pressure• Tumors
• Congenital
• Spontaneous
• Spontaneous CSF rhinorrhea is a distinct clinical entity and occurs in the absence of any inciting event.
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Why does it matter?Spontaneous v. another etiology
• Endoscopic repair: 90‐95% success rate– Standard of care
– Excellent visualization
– Avoid frontal craniotomy
• Spontaneous CSF leak: 13‐75% success rate historically
• Increased ICP: negative risk factor for repair
Hubbard et al. Neurosurg 1985; Ommaya J Neurol Neurosurg 1968; Mirza Laryngoscope 2005; Schnick Ann Otol Rhinol, Laryngol 2001; Schlosser Laryngoscope 2002
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Do spontaneous CSF leaks represent a distinct clinical entity and a variant
of idiopathic intracranial hypertension?
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Normal CSF Physiology
• Normal CSF pressure: 5‐15 cm H20
• Total CSF volume: 90‐150 mL
• CSF production: Choroid plexus 0.35 mL/min
• CSF absorption: Arachnoid villi acts as a one‐way valve
– Pressure gradient of 1.5 – 7 cm H20 for antegrade flow
Daube et al Medical Neurosciences 1986
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Clinical Presentation and Evaluation
• Obese, middle aged females with clear unilateral watery rhinorrhea
• β ‐2 transferrin or β‐trace protein
• Localization
– High resolution CT of skull base
– MRI
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Spontaneous CSF Leaks and IIH
Spontaneous CSF leak
• Female sex (70‐80%)
• Obesity (82‐92%)– Average BMI 35.4
• Reproductive age (78%)
• Symptoms
– Pressure‐like headache (91%)
– Pulsatile tinnitus (45%)
– Watery rhinorrhea
Idiopathic Intracranial Hypertension• Female sex (90%)
• Obesity (94%)– Average BMI 33
• Reproductive age (70%)
• Symptoms
– Headache (98%)
– Pulsatile tinnitus
– Visual changes (48%)
Wang Oto Clin North America 2011
70% of Spontaneous CSF Leak patient would have IIH by Dandy criteria
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Obesity, Spontaneous CSF leaks and IIH
• BMI >30 10‐20 fold incidence of IIH
• Average BMI
– Spontaneous CSF leak: 35.4
– Traumatic CSF leak: 29.7
Radhakrishnan J Neurol Sci 1993, Banks OtoHNS 2009
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
CT: Spontaneous CSF Leaks
Attenuated Skull Base Normal Skull Base
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Common Sites of Spontaneous CSF Leaks
Lateral Recess of Sphenoid Cribiform/Ethmoid Roof
Multiple meningoencephaloceles in spontaneous CSF leaks: up to 31%
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
MRI: Spontaneous CSF Leaks
1. Empty Sella Syndrome2. Bilateral meningoceles3. Dilated Optic Nerve
Sheathes
1 2
3
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Radiographic Findings of IIH
• Double Blinded Case Control Study
1. Empty Sella Syndrome
2. Abnormalities of the Optic Nerve
3. Arachnoid Pits
4. Flattening of the Posterior Globe/Skull Base
Agid et al Neuroradiology 2006
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Empty Sella Syndrome
Herniation of meninges and CSF through weakened sellar diaphragm into sella turcica compresses pituitary
Association with ESS:• Spontaneous CSF rhinorrhea: 76%
• Multiple spontaneous meningoceles: 100%
• Spontaneous CSF otorrhea: 80%
• IIH: 84%
Marker of successful treatment of increased ICP?
Normal sella
Empty sella
Schlosser OtoHNS 2003; Silver Am J Rhino 2007; Kutz Laryngoscpe 2008; Goddrd Otol Neurotol 2008; Zagardo AJNR 1996
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Direct Evidence of Increased ICP in Spontaneous CSF Leaks
• IIH diagnosis requires ICP of 25 cm H20
• ICP after endoscopic repair in spontaneous CSF leak: 27 and 32.5 cm H20
• ICP after endoscopic repair in traumatic CSF leak: 14 cm H20
• Case series reporting development of classic IIH symptoms after repair of CSF leak
Schlosser OtoHNS 2004; Schlosser Am J Rhino 2003; Woodworth OtoHNS 2008
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Evidence support Spontaneous CSF leaks as a variant of IIH
• Strikingly similar demographics and symptoms
– Level 2B
• Overlap of radiographic findings
– Level 2B
• Increased ICP after endoscopic repair
– Level 2B
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Can a reduction in CSF pressure alone be used to treat CSF leaks?
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Reduction in CSF pressure
• Medications– Acetazolamide– Topiramate
• Shunting– Lumboperitoneal shunting– Ventriculoperitoneal shunting
• Weight loss– Gastric bypass reduced CSF pressure from 35.3 to 16.8 cm H20 Sugerman Ann Surg 1999
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Case Reports
• Spontaneous CSF leak after VP shunt failure that resolved after shunt revision Ransom et al Clin Neurosci 2006
• 3 separate case reports of cessation of CSF leaks after gastric bypass surgery and weight loss for IIH Rudnick Otol Neurotol 2005; Stangherlin Acta Chir Belg 2008; Sugerman Ann Surg 1999
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Case Example
• 62 year old female with moderate obesity presents with the acute onset of left sided watery rhinorrhea two weeks ago.
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Spontaneous Encephalocele
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Nasoseptal Flap Reconstruction
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Spontaneous CSF Leak: Endoscopic Repair
• 53 yo obese female initially admitted for meningitis with pansinusitis
• After resolution of meningitis, she reports a history of right sided clear rhinorrhea for 3‐4 years
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Encephalocele of the Lateral Recess of the Sphenoid
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Spontaneous CSF Leak: Endoscopic Repair
• 43 yo obese female who presents with watery rhinorrhea
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Left trans‐pterygoid approach to middle fossa
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Does decreasing ICP improve outcomes of endoscopic repair of spontaneous CSF leaks?
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Perioperative Concerns
• After repair and no further CSF diversion, ICP increase to 27‐32.5 cm H20
• Possible stress on repair
• Lumbar drains?
• Medical therapy?
• Shunting?
Schlosser OtoHNS 2004; Schlosser Am J Rhino 2003; Woodworth OtoHNS 2008
No Randomized Controlled Trials
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Lumbar Drains as Diagnostic Tools
• University of Pittsburgh Carrau Laryngoscope 2005– 19 Patients with increased ICP underwent
endoscopic repair with diagnostic LD– If persistently elevated ICP VP shunt– 100 % success rate
• University of Pennsylvania Woodworth OtoHNS 2008
– 77 Spontaneous CSF leak patients underwent endoscopic repair with diagnostic LD
– If ICP > 15 cm H20 acetazolamide– If ICP > 35 cm H20 VP shunt– 95% success rate
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
A look at the failures out of Penn
• 6 failures
– 3 at a second site, failure to control ICP
– 3 failed after VP shunt malfunction
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Acetazolamide and CSF leaks
• Carbonic anhydrase inhibitor
• Reduces CSF production by 48%
• Mean reduction of 10 cm H20
• Report decrease in tinnitus, headache
• No long term benefit demonstrated
Schlosser OtoHNS 2004; Woodworth OtoHNS 2009; Carrion Arch Dis Child 2001
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Carbonic Anhydrase Inhibitors and IIH
• Acetazolamide: Conflicting evidence in vision
– Visual fields: effective
– Papilledema: ineffective
• Topiramate & Acetazolamide
– Both effective for IIH: Headaches, Tinnitus, and visual fields
– Topiramate: Weight Loss
• Cochrane review: insufficient data to recommend
Lueck Cochrane 2009; Celebisoy Acta Neurol 2007; Johnson Ophthalmology 1998
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Shunting
• Spontaneous CSF Leaks
– Effective in 2 larger case series
• Empty sella syndrome
– Neurological symptoms
– Visual symptoms
– Repair of CSF leaks
• IIH
– Preventing visual loss
Carrau Laryngoscope 2005; Woodworth OtoHNS 2008; Maira J Neurosurg 2005; Brazis Cephalagia 2008
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Why not shunt everyone?
• Shunt failure rate: 3‐10%
• Infection (27%)
• Overdrainage issues
• Estimated 40‐50% shunts are removed at 2 years
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Evidence supporting Reduction in ICP after Repair of Spontaneous CSF leaks
• Medical reduction of ICP i.e acetazolamide
– Level 4
• CSF diversion
– Level 4
• Weight loss
– Level 5
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Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Grade of Evidence Summary
Evidence based Question Grade of Evidence
Association between IIH and Spontaneous CSF leaks B
Etiologic role of increased ICP in spontaneous CSF leak B
Decreasing ICP alone for treatment of spontaneous CSF leak D
Improving outcomes after endoscopic repair by decreasing ICP (medical or CSF diversion)
C
Wang Oto Clin North America 2011
Fourth Annual ENT for the PA-C | April 24-27, 2014 | Pittsburgh, PA
Conclusions
• Spontaneous CSF leaks are a distinct entity that is likely a variant of IIH
– Demographic, Clinical and Radiographic
• Decreasing ICP may improve successful outcomes after endoscopic repair
– Case series