Subcranial transnasal repair of cerebrospinal fluid rhinorrhea with free autologous grafts by the combined overlay and underlay techniques.

Objective: To determine the efficacy of subcranial transnasal repair of cerebrospinal fluid rhinorrhea with free autologous grafts by the combined overlay and underlay techniques using the surgical microscope and/or endoscope.

Methods: Twenty patients with CSF rhinorrhea were included in this retrospective study. They were 13 males and 7 females. Their age ranged from 7 to 62 years (mean: 39.35). The etiologies of the leak were iatrogenic in 10 cases, spontaneous in 5 cases, traumatic in 4 cases and one case was associated with meningeo-encephalocele. Preoperative nasal endoscopic examination, computed tomography (CT) with intrathecal non-ionic contrast and magnetic resonance imaging (MRI) were done when indicated. Endoscopic and/or microscopic repair of the CSF fistula was done by a combination of both underlay and overlay repair with free autologous grafts as follows: Gelfoam with fibrin glue, strips of fat, facia lata, Gelfoam with fibrin glue (underlay), septal cartilage, Gelfoam with fibrin glue and strips of fat (overlay).

Results: Complete closure of the leak was achieved in all patients. In one case of spontaneous CSF leak which was operated endoscopically, the leak recurred 6 months postoperatively and ceased spontaneously after a month with conservative medical treatment. No major complications were seen and no patients developed meningitis or postoperative anosmia.

Conclusions: Subcranial transnasal repair with free autologous grafts by the combined overlay and underlay techniques using the endoscope or surgical microscope is a safe and successful method of treating CSF leaks, provided that the CSF leak is precisely located and the site can be reached with the endoscope or surgical microscope.