Endoscopic Endonasal Orbital Transposition, for Closure of Lateral Frontal Sinus CSF Rhinorrhea: A Case Report

BACKGROUND

Cerebrospinal fluid (CSF) rhinorrhea is the communication of the subarachnoid space to the nasal cavity.¹ It requires to be corrected with surgical intervention, an exception for traumatic CSF leak where we can wait for spontaneous closure from 10 to 14 days. About 15% of the cases of CSF rhinorrhea occur in the frontal sinus area.² They are generally classified as traumatic, neoplastic, and spontaneous and arise from sphenoid, ethmoid, frontal sinuses, or cribriform areas.³ About 77 case reports from Banks et al.⁴ with spontaneous CSF leak, in which only 11.7% arose from the frontal sinus. In 1926, Dandy did the first surgical repair of CSF rhinorrhea through a frontal craniotomy approach. Wigand described his first endonasal endoscopic repair of CSF rhinorrhea in 1981.^5,6 We report a series of 3 cases of lateral frontal sinus CSF rhinorrhea and they are successfully treated by endoscopic endonasal with orbital transposition.

CASE DESCRIPTION

DISCUSSION

The frontal sinus leak site arises from the anterior to the anterior ethmoidal artery and an extended frontal sinusotomy approach needed for adequate access for the skull base reconstruction. However, the CSF leaks in the lateral aspect of frontal sinuses still remained a difficult to approach area with a pure endonasal endoscopic approach. Hence these cases were mostly tackled by a frontal craniotomy, osteoplastic flap, brow minicraniotomy, and endoscopic frontal sinusotomy with an external trephine. The trephine approach in frontal sinus CSF leak is replaced endoscopic endonasal approach.²

Frontal sinus anatomy is complicated, reaching lesions present in the extreme lateral aspect of the sinus is difficult when the frontal sinus is much pneumatized, the convex angle of the orbital roof, interorbital distance, and anteroposterior diameter of the frontal recess must be adequate (>1 cm) to initiate access. Draf type III frontal sinusotomy provides good lateral access to the frontal sinus. It can be extended further by increasing the space of the frontal recess in the superomedial orbital wall decompression after coagulation and anterior ethmoidal artery sectioning and lateral orbital transposition. So, if draf type III is combined with the orbital transposition, it is possible to access the contralateral nasal fossa. Periorbital should be preserved, even removal of the superomedial wall of the orbit may cause an intraoperative herniation of the orbital content and will not need any reconstruction. Periorbital is firm and it will not allow the orbital contents to expand and preserves the patient from diplopia and enophthalmos.^7–10 Large skull base defects can be repaired endoscopically using vascularized flaps like hadad flap and Janus flap, and the far lateral defects in sphenoid sinuses could be repaired using the trans pterygoid approach.^11,12

The contraindications to the endoscopic endonasal approach:⁸

• If frontal sinus anteroposterior diameter and interorbital distance are small

• The posterior wall of the frontal sinus eroded, with a large intracranial multilobulated lesion

• The lesion in lateral supraorbital attachment

• Far lateral portion of the frontal sinus squamous cell carcinoma which is histologically proved

• Previous surgical scar

• High solidity of an osteoma

Endoscopic transposition for frontal sinus was described by Karligkiotis A et al.⁸ Their cases did not include CSF leaks. We used the same technique to address 3 cases with CSF rhinorrhea in the lateral aspect of the frontal sinus. In all cases, we got consent from the patients to switch the procedure to a combined endoscopic-osteoplastic approach if required from the endoscopic approach. Experience is needed in these types of approaches to avoid orbital complications.¹³

CONCLUSION

Functional endoscopic endonasal sinus surgery with angled scopes and powered instruments provides access to the lesions extended laterally into the frontal sinus.^8,14 The advantages of endoscopic repair when compared to frontal craniotomy are the absence of brain retraction, preserved olfaction, external incision, and scar. Moreover, for large skull base reconstruction, vascularized flaps are needed, so a hadad flap is a good choice instead of an osteoplastic flap. Since the endoscopic approach is minimally invasive and had greater than 90% success rates.

REFERENCES

1. Gupta M, Gupta M, Bindra G, et al. Idiopathic sphenoid sinus CSF rhinorrhoea. BMJ Case Rep 2013;2013:bcr2013009416. DOI: 10.1136/bcr-2013-009416.

2. Jahanshahi J, Zeinalizadeh M, Reza Mohammadi H, et al. Endonasal endoscopic management of frontal sinus cerebrospinal fluid leak. Am J Rhinol Allergy 2017;31(6):406–411. DOI: 10.2500/ajra.2017.31.4478.

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13. AlQahtani AA, Albathi AA, Alhammad OM, et al. Innovative real CSF leak simulation model for rhinology training: Human cadaveric design. Eur Arch Otorhinolaryngol 2018;275(4):937–941. DOI: 10.1007/s00405-018-4902-y.

14. Turri-Zanoni M, Dallan I, Terranova P, et al. Frontoethmoidal and intraorbital osteomas: Exploring the limits of the endoscopic approach. Arch Otolaryngol Head Neck Surg 2012;138(5):498–504. DOI: 10.1001/archoto.2012.644.