RHINOLOGY

Sandwich grafting technique for endoscopic endonasal repairof cerebrospinal fluid rhinorrhoea

Magdy Eisa Saafan • Osama A. Albirmawy •

Mohamed Osama Tomoum

Received: 14 May 2013 / Accepted: 19 August 2013 / Published online: 28 August 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract The surgical management of cerebrospinal fluid

(CSF) rhinorrhoea has changed significantly after the

introduction of functional endoscopic sinus surgery. The

clear anatomical exposure of the roof of the nasal and

paranasal sinus cavities by the endoscope offers the sur-

geon a golden chance to identify the area of CSF leak, and

thus enables one to adequately plan the management. The

aim of this work is to evaluate the use of facia lata sand-

wich graft technique for endoscopic endonasal repair of

CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were

treated endoscopically using 2 layers of facia lata (underlay

and onlay) interposed with a layer of septal cartilage or

conchal bone in-between (sandwich technique) for repair.

Fifty-five percent of cases were regarded as spontaneous

CSF leaks with no obvious cause, 30 % following head

injury and 15 % were iatrogenic. The ethmoidal roof was

the commonest location of CSF leak (60 %) followed in

frequency by the cribriform plate and the sphenoid sinus

(20 % each). Follow-up period was 12–24 months. We

have achieved a 95 % success rate in managing CSF leaks

in our 40 patients in the first attempt repair and 100 %

success rate after second attempt repair. Endoscopic en-

donasal repair of CSF leaks is quite safe and effective

procedure with high success rate and avoid the morbidity

associated with craniotomy. Using the three-layer, sand-

wich-grafting technique of facia lata further adds more

security to the sealing of CSF and augments the results of

repair.

Keywords CSF � Rhinorrhoea � Facia lata �Endoscopic � Endonasal � Graft � Repair

Introduction

Cerebrospinal fluid (CSF) rhinorrhea occurs because of an

abnormal communication between the subarachnoid space

and the sinonasal tract. The defect can occur anywhere

along the ventral skull base, which includes the cribriform

plate, fovea ethmoidalis, sphenoid bone, temporal bone, or

posterior table of the frontal sinus [1].

CSF rhinorrhea may be classified by cause as traumatic

or non-traumatic. Traumatic CSF rhinorrhea included

under this classification are iatrogenic injuries (from

intracranial or extracranial surgery) or external trauma

(penetrating or blunt). Non-traumatic causes produce direct

erosion or increased intracranial pressure and result from

intracranial tumors, congenital or acquired hydrocephalus,

or infections such as osteomyelitis and tuberculosis.

Spontaneous (or primary) CSF rhinorrhea may also be

classified as a non-traumatic cause. Meningoceles or

meningoencephaloceles may also occur with both trau-

matic and non-traumatic causes [2].

Most CSF leaks resulting from accidental and surgical

trauma heal with conservative measures over the course of

7–10 days. Less likely to heal spontaneously are leaks in

which CSF rhinorrhea develops days or weeks after sur-

gical or accidental trauma, massive leaks that develop

Magdy Eisa Saafan takes responsibility for the integrity of the content

of the paper.

M. E. Saafan (&) � M. O. Tomoum

Department of Otolaryngology and Head and Neck Surgery,

Tanta Faculty of Medicine and University Hospitals,

61 KafrEsamStreet, ElNadi Square, Tanta, Egypt

e-mail: eisamagdy@hotmail.com

O. A. Albirmawy

Department of Otolaryngology and Head and Neck Surgery,

Tanta University Hospitals, Tanta, Egypt

123

Eur Arch Otorhinolaryngol (2014) 271:1073–1079

DOI 10.1007/s00405-013-2674-y

immediately after surgery, leaks caused by sustaining

gunshot wounds, or normal-pressure CSF leaks. CSF fis-

tulae found at the time of endoscopic sinus surgery require

repair at the time of initial surgery. Leaks noted 5–7 days

after surgery may close spontaneously; if there is no res-

olution in 1–2 weeks, surgery is indicated. First-line

treatment includes bed rest with head elevation, avoidance

of straining activity such as nose blowing, sneezing, and

coughing, and the use of stool softeners. Antibiotic pro-

phylaxis remains controversial [3].

The first documented attempt at repairing a CSF leak

was made by Dandy in 1926 through a frontal craniotomy

[2]. The evolution of cerebrospinal fluid (CSF) fistula

repair reflects a desire to reduce the high failure rate and

significant morbidity associated with earlier approaches

[4]. Transcranial approaches for repair of CSF rhinorrhea

can be associated with some morbidity including cerebral

contusion, intracranial hemorrhage, cerebral edema, anos-

mia, pneumocephalus, bifrontal retraction injury, venous

infarction, and bone flap infection [5].

Over the past 30 years, the advent and advancement of

endoscopic instrumentation has seen the replacement of

sometimes debilitating open approaches with minimally

invasive, entirely endoscopic ones [4]. Following Wigand’s

[6] first documentation of a successful endoscopic CSF

leak repair in 1981, the endonasal approach has largely

replaced open methods of repair. In 2000, Hegazy et al. [7]

examined the initial experience with endoscopic CSF leak

repair, summarizing 14 studies published between 1990

and 1999. The primary success rate for these initial studies

ranged from 60 % to 100 %, with an average of 90 %.

Since that publication, the popularity of endoscopic CSF

leak repair has continued to increase, new methods have

been developed, and many larger and more diverse case

series have been published [4].

If the patient has increased CSF pressures, attempt

should be made to place a rigid underlay graft, such as

bone, into the epidural space. Leaks from other etiologies

that have normal intracranial pressures probably do not

require rigid grafting and can be repaired successfully

using soft tissue grafts. Options for rigid grafting include

bone grafts from the nasal septum, turbinates, or mastoid.

A variety of soft tissue materials may be used for underlay

or overlay grafts, including temporalis fascia, fascia lata,

cadaveric dermis or fascia, or free mucosal or mucoperic-

hondrial grafts [8]. These materials may be used underlay

(i.e. between the dura and skull base bone) or overlay (i.e.

over the nasal side of the defect) patches or to obliterate the

affected sinus [9].

Controversy also exists regarding the use of fixators

such as packing and/or fibrin glue, and postoperative

adjunctive management, such as the use of a lumbar drain

and perioperative antibiotics. Following graft placement, a

sealant (such as fibrin glue) can be used to hold the graft in

place. Absorbable nasal packing (gel-foam) is usually

placed directly against the mucosal surface of the graft for

additional support, followed by placement of non-absorb-

able packing for further support and hemostasis. Packs are

usually removed in 5–7 days [10].

Patients and methods

In this prospective study, 40 patients with CSF rhinorrhoea

were treated at the ENT Department of Tanta University

Hospital between January 2008 and June 2011. They were

managed with endoscopic endonasal approach using

sandwich grafting technique. Patients were subjected to

detailed history-taking in an attempt to find a cause for CSF

leak, ENT examination, neurosurgical evaluation and nasal

endoscopic examination. CT cisternography using metriz-

amide as a contrast, high-resolution thin-section coronal

and axial CT of the paranasal sinuses were done in all

cases, while MRI was done in some cases for better soft

tissue delineation, and helps in the preoperative localiza-

tion of the site of the leak, Figs. 1, 2, 3, 4, 5.

Endoscopic repair was carried out by the senior author.

Standard FESS technique was performed, where uncinec-

tomy, anterior, posterior ethmoidectomy and whenever

needed sphenoidotomy and/or frontal recess cleaning were

accomplished with careful preservation of the middle tur-

binate. The skull base was identified and exposed. For

Intraoperative localization of the defect, direct nasal

endoscopy was used in addition to topical application of

5 % fluorescein [11]. A change of the color of fluorescein

from yellow to green fluorescence denotes the presence of

CSF, and the site of the leak could be traced, Fig. 6a. When

the defect was small, increasing CSF pressure by causing

the patient to cough against a cuffed endotracheal tube

helps to identify the leak. After localization of the defect,

mucosa was denuded from the edges and the field became

ready to receive the graft.

A facia lata free graft was then harvested from the upper

outer aspect of the thigh with an average size of 5 9 5 cm,

but larger sizes were possible when needed. Facia lata has

the advantage of being tough enough and durable, also no

size limit is present. Whenever needed, fat was also taken

from the same site. Back again to the defect in the skull

base where a piece of facia lata was fashioned, a little bit

larger than the defect size, and was placed above the edges

of the defect in the epidural space as an underlay graft (1st

layer), Fig. 6b. A piece of septal cartilage or a lamella of

bone from the lateral aspect of the middle turbinate (when

septal cartilage was not readily available due to previous

septal surgery) was fitted to close the bony defect in the

skull base (2nd layer), Fig. 6c. A second but larger piece of

1074 Eur Arch Otorhinolaryngol (2014) 271:1073–1079

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facia lata was applied as an onlay graft over the bone or

cartilage (3rd layer), Fig. 6d. This is the basic three-layer

sandwich technique. In addition, in case of defects of the

ethmoidal roof a trap-door flap of the middle turbinate was

fashioned where, the lateral aspect of the vertical part of

the middle turbinate was removed (sometimes used as the

second layer after denuding it from epithelium) and the

medial lamella was rotated laterally to cover and support

the sandwich graft, Fig. 6e. Also in cases where the leak

Fig. 1 a Coronal CT of the nose and paranasal sinuses showing a defect in the medial side of the left ethmoidal roof. b Axial T1w MRI of the

same patient showing the site of the CSF leak from the left posterior ethmoid

Fig. 2 Coronal CT of the nose and paranasal sinuses showing a

defect in the left cribriform of ethmoid posteriorly

Fig. 3 Coronal CT of the nose and paranasal sinuses showing a

defect in the roof of the posterior ethmoid

Fig. 4 Coronal CT of the nose and paranasal sinuses showing a

defect in roof of the right anterior ethmoids

Fig. 5 Coronal CT of the nose and paranasal sinuses showing

complete opacification of the right sphenoid with a defect in its lateral

wall

Eur Arch Otorhinolaryngol (2014) 271:1073–1079 1075

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was in the sphenoid sinus, fat plug was used to fill the sinus

cavity as a pack which gives more support to the sandwich

graft. In case of defects in the cribriform plate and sphe-

noid sinus, it was not always possible to apply the underlay

graft along the whole circumference of the defect, so the

first layer was more or less a reverse-through graft, and in

these cases a piece of fat was used as a plug and inserted

before the facia lata to achieve immediate seal of the CSF

leak. Surgicel strips were then applied to support the graft,

and finally a nasal pack of sofratol (antibiotic impregnated

Vaseline gauze) was applied to ensure the graft would not

become displaced, and was left in situ for a minimum

duration of 1 week. No tissue glues were used, we relied on

the complete seal of several graft layers which was sup-

ported with the trap-door flap then surgicel and finally the

nasal packing. No postoperative lumbar punctures or

lumbar drains were used. Patients were kept on antibiotics,

with bed rest, head elevation, refraining from nasal blow-

ing and cough for 10–14 days.

Fig. 6 a Intraoperative

endoscopic view after topical

fluorescein application showing

a yellow green area at site of

CSF leak in left ethmoidal roof.

b Intraoperative endoscopic

view showing the 1st layer of

repair (underlay facia lata).

c Intraoperative endoscopic

view showing the 2nd layer of

repair (Conchal bone).

d Intraoperative endoscopic

view showing the 3rd layer of

repair (onlay facia lata).

e Intraoperative endoscopic

view showing a trap-door flap of

the middle turbinate.

f Endoscopic view 4 months

postoperatively showing

complete healing of the skull

base defect

Table 1 Symptoms of the patients

No. of patients Percentage

Rhinorrhoea 40 100 %

Headache 24 60 %

Sinus congestion 24 60 %

Anosmia and hyposmia 8 20 %

Meningitis 2 5 %

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Postoperative follow-up included endoscopic nasal suc-

tioning and care of the nasal wound at regular intervals of

5–7 days for 3–4 weeks till healing of the cavity. Longer

follow-up was arranged in the form of clinical and endo-

scopic nasal examination every 3 months for 12–24 months.

Results

Forty patients with CSF rhinorrhoea were treated at the

ENT Department of Tanta University Hospital between

January 2008 and June 2011. Patients were 18 males and

22 females with the age range between 25 and 46 years

(mean 34.8 years). Unilateral watery rhinorrhoea was the

commonest preoperative symptom being present in all

cases, headache, sinus congestion; small disorders (anos-

mia and hyposmia) were also reported, (Table 1). Two

cases had meningitis and received its appropriate medical

treatment preoperatively.

Regarding the etiology, 22 cases were regarded as

spontaneous CSF leaks with no obvious cause, 12 cases

following head injury and 6 cases were iatrogenic follow-

ing FESS for management of diffuse sinonasal repair. The

size of the defect ranged from 3–15 mm to 4–17 mm as

measured by CT scans. The ethmoidal roof, mostly the

lateral lamella of the cribriform, was the commonest

location of leak in this series followed in frequency by the

cribriform plate and then the lateral wall of the sphenoid

sinus (Table 2).

All patients were managed by endoscopic endonasal

approach using facia lata sandwich grafting technique.

Sandwich grafting technique could be achieved in all cases

but when the defect was in the cribriform plate and the

posterolateral wall of the sphenoid the underlay graft could

not be applied totally underlay due to technical difficulties,

so it was more or less reverse through in some parts.

Follow-up ranged from 12 to 24 months. No major

complications occurred in any of our patients. Only one

case developed orbital ecchymosis which resolved with

appropriate medical treatment. None of the cases devel-

oped postoperative meningitis.

Of 40 patients, 38 (95 %) had successful repair of the

cranionasal fistulae as evidenced by resolution of CSF

rhinorrhea (Table 3; Fig. 6f). Two patients required a

second endoscopic procedure. The recurrence of CSF rhi-

norrhea was 3 months and 5 months after the first repair.

These two patients have had a successful second endo-

scopic repair result with 12 months of follow-up.

Discussion

The diagnosis, localization, and management of cerebro-

spinal fluid rhinorrhea remain an ongoing clinical chal-

lenge [12].

Cerebrospinal fluid (CSF) leaks can be broadly catego-

rized as iatrogenic, traumatic, or spontaneous in etiology.

Although many leaks (particularly traumatic leaks) resolve

with conservative management, surgical closure of the

persistent CSF leak is necessitated by a high incidence of

bacterial meningitis in such cases. The popularization of

functional endoscopic sinus surgery (FESS) in the 1980s

created the most common source of iatrogenic CSF rhi-

norrhea, but also provided a potentially far less morbid

approach for repair of leaks from any etiology, as first

reported by Wigand in 1981 [13].

Localization of the dural defect is critical to manage-

ment of CSF leaks. Radiographically, a high-resolution

computed tomography (HRCT) scan performed in axial

and coronal planes using fine cuts can be used to identify a

cranial base defect [14]. It is important to recognize that

congenital or acquired thinning or absence of portions of

the bony skull base may be identified and may not neces-

sarily correspond to the site of CSF leak. Intrathecal agents

have been used both to confirm the presence of and to

attempt to localize CSF leaks [10]. Intrathecal fluorescein

has been associated with multiple complications, including

grand mal seizures and even death. To overcome such

drawbacks of intrathecal fluorescein as well as the reluc-

tance of anesthesiologists to inject it, the use of intranasal

topical fluorescein for intraoperative localization of CSF

fistulas was coined by Jones et al. [15]. They tested it in a

Table 2 Aetiology and site of the CSF leak

No. of

patients

Percentage

Location of fistula

The ethmoidal roof, mostly the lateral

lamella of the cribriform

24 60 %

Cribriform plate 8 20 %

Sphenoid sinus (lateral wall) 8 20 %

Possible etiology

Spontaneous 22 55 %

Traumatic 12 30 %

Iatrogenic 6 15 %

Table 3 Results of first and second repairs

Results Percentage of patients (%)

Successful first repair 38/40 (95 %)

Successful second repair 2/2 (100 %)

Total successes 40/40 (100 %)

Unsuccessful 0/0 (0 %)

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very small series of three patients reporting their success to

localize the defect in the three cases with no complications.

In our previous study [11], the use of topical fluorescein

was accurate in localizing the defect in 25 cases, with

absolutely no mentioned complications, demonstrating an

easy, safe, and sensitive approach and providing a viable

noninvasive alternative to the intrathecal injection of

fluorescein in the intraoperative localization of CSF fistulas

[11]. In the present study, we used topical application of

5 % fluorescein intranasally, a change of the color of

fluorescein from yellow to green fluorescence denotes the

presence of CSF, and the site of the leak could be traced.

Among autologous tissues for grafting, there are tissues

with stiffness as septal cartilage, the bone of the middle

turbinate, vomer, ethmoidal perpendicular plate, and

mucosal tissues that fill the defects such as temporalis

fascia, fascia lata, or free mucosal or mucoperichondrial

grafts, and finally fat. Among the heterologous materials

are dural substitutes such as the equine collagen matrix.

Other biomaterials are represented by polytetrafluoroeth-

ylene foam and fibrin glue, which are used individually or

in association with autologous tissue; the use is preferred in

larger lesions, as in the case of repair of encephalocele

[16].

Studies in the literature have demonstrated a significant

improvement in the results in the plastic skull base using a

multilayer technique, and for this reason, in our work, we

have always positioned the three layers for the repair of

bone defect [17, 18]. No doubt, use of multiple layers

would augment the chances of success; we may have this

concept also in myringoplasty. Facia lata is strong enough,

durable and readily accessible graft that can be taken freely

in any size, as we used it for underlay and onlay grafting

(1st and 3rd layers). We used septal cartilage (or conchal

bone when it was not available) as a second layer to give

rigid support to the skull base to prevent herniation of

intracranial contents. We further augmented these three

layers with a trap-door flap from the middle turbinate. In

this study, use of multi-layers was successful in closing the

defect in 38 cases (95 %) in first attempt repair and 100 %

in second attempt repair after 12–24 months follow-up. We

strongly advocate use of this approach when dealing with

large defects in the skull base, bilateral defects, revision

cases and complicated cases.

Throughout the literature, the choice of grafting mate-

rials and technique of endoscopic repair of CSF fistulas

seems to depend on the experience and familiarity of the

operating surgeon with various techniques. Most tech-

niques yield similar results in experienced hands. Weber

et al. [19] described the use of underlay technique in 25

patients, while an onlay technique in 22 patients had sim-

ilar success rates. Zweig et al. [9] in a series of 48 cases,

reported the use of 11 different grafting materials with the

turbinate mucosa and septal mucoperiosteum being the

most common grafts using underlay, onlay and/or obliter-

ative techniques and reported 95 % success rates.

Schlosser et al. [20] in a systematic review of 55 studies,

2 prospective and 53 retrospective studies from 1985 to

2010 which involved a total of 1,778 CSF leaks demon-

strated successful leak closure in 90.6 % of endoscopic

CSF leak repairs after the first attempt, that increased to

96.6 % with the second attempt. The overall complication

rate was very low at 0.03 %. These results remain superior

to previous series involving external approaches [21, 22],

and are comparable to the previously published but much

smaller systematic review by Hegazy et al. [7].

Lanza et al. [23] identified the following factors that

might predispose to failure: inability to localize the defect,

graft displacement, insufficient graft size, incomplete

apposition of the graft to the skull base, patient noncom-

pliance and poor wound healing.

Conclusion

From our work, we can conclude that endoscopic endo-

nasal repair of CSF leaks is quite safe and effective pro-

cedure with high success rate and avoid the morbidity

associated with craniotomy. Using the three-layer, sand-

wich-grafting technique of facia lata further adds more

security to the sealing of CSF and augments the results of

repair.

Conflict of interest The authors have no conflict of interest,

financial or otherwise with any organization.

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