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Register a new userEndoscopic Trans-nasal Management Of CSF Rhinorrhea
تدبير سيلان السائل الدماغي الشوكي عبر الأنف بالتنظير
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نبيل دندشلي( باحث )
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خلفية البحث و هدفه: تدبير حالات سيلان السائل الدماغي الشوكي الأنفي عبر طريقة فعالة و غير راضة بالتنظير عبر الأنف مقارنة بالجراحة التقليدية عبر خزع القحف الخارجي. هدف هذا البحث إلى إجراء دراسة تفصيلية لحالات سيلان السائل الدماغي الشوكي من الأنف، و دراسة نتائج التدبير عبر جراحة الجيوب التنظيرية و نسب النكس. مواد البحث و طرائقه: جرت دراسة راجعة لملفات المرضى المقبولين بالشعبة الأذنية في مستشفى المواساة الجامعي في دمشق 2004-2009.بتشخيص ناسور سحائي أنفي، و أجري لهم إغلاق عبر الأنف بمساعدة المناظير،بلغ عدد الحالات 34 حالة (مجموعة أولى رئيسة) أضيف إليها ثلاث حالات حدث فيها الناسور خلال عملية جراحة جيوب تنظيرية بسبب استطبابات أخرى ضمن المدة نفسها (مجموعة ثانية ثانوية). النتائج: كان العرض الرئيس عند مرضى المجموعة الأولى عند مراجعة المستشفى هو سيلان رائق من الأنف مستمر أو متقطع عند 30 مريضاً ( 88.23 %) ، تكرر التهاب سحايا عند أربعة مرضى ( 11.76 %)و سيلان مع قصة التهاب سحايا عند مريض واحد ( 2.94 %). لوحظ وجود قصة رض على الرأس عند 20 مريضاً ( 58.82 %)، قصة تداخل جراحي على الأنف (يعتقد أنه سبب للناسور) عند 4 مرضى ( 11.76 %) في حين لم يذكر 10 مرضى ( 29.41%) أي قصة رض أو تداخل جراحي. توضع الناسور في سقف الجيب الغربالي عند 28 مريضاً ( 79.41 %)، سقف الجيب الوتدي أو جداره الجانبي عند 4 مرضى ( 11.76 %) و في سقف الجيبين الغربالي و الوتدي معاً عند مريضين(%5.88 ). أجري إغلاق للناسور عند مرضى المجموعتين عبر عملية جراحة جيوب تنظيرية، و استعمل لذلك صفاق العضلة الفخذية عند 31 مريضاً ( 83.78 %)، صفاق العضلة المستقيمة البطنية عند مريض واحد ( 2.7 %) و الغشاء المخاطي السمحاقي من القرين السفلي للطرف المقابل عند 5 مرضى ( 13.51%). روقبت المرضى مدة راوحت بين 12-43 شهراً. حدث النكس عند 10 مرضى بشكل عودة السيلان المائي من الأنف أو بمعاودة التهاب السحايا أو الاثنين معاً. أعيد العمل الجراحي التنظيري عبر الأنف عند 8 مرضى، و حدث النكس الثاني عند ثلاثة منهم. و من جرى فإن إغلاق الناسور جرى بنجاح عبر الجراحة التنظيرية عند 91.42 % من المرضى. الاستنتاج: إن التداخل عبر الأنف بمساعدة المنظار هو طريقة فعالة في تدبير سيلان السائل الدماغي الشوكي من الأنف مع نسب إمراضية و وفيات قليلة جداً مقارنة بالطريق الجراحي العصبي المفتوح.
Background& Objective: Management of CSF rhinorrhea by an effective and less traumatic endoscopic tans-nasal approach in comparison with traditional open craniotomy one. Objective: To study cases of CSF rhinorrhea and to evaluate the results of Endoscopic trans-nasal repair and failure rates. Materials & Methods: Retrospective study of 34 cases (first main group) of meningeal nasal fistula admitted to Al Moassate university hospital between 5.2004 - 5.2009 in addition to three cases in which the fistula had occurred during an endoscopic sinus surgery (second secondary group). Results: In the first group the main presenting complain was persistent or intermittent clear watery rhinorrhea in 30 patients (88.23%), history of repeated Meningitis in 4 patients (11.76%) and rhinorrhea and one episode of meningitis in one patients (2.94%).A history of head trauma was detected in 20 patients (58.82%), nasal surgery in 4 patients (11.76%), where no history of head trauma or nasal surgery was found in 10 patients (29.41%). The fistula situated in the roof of the ethmoid sinus in 28 patients (79.41%), roof or lateral wall of sphenoid sinus in 4 patients(11.76%), and in the roof of both ethmoid and sphenoid sinuses in tow patients(5.88%). The fistula was closed by endoscopic trans-nasal approach with fascia latta in 31 patients (83.78%), fascia of rectus abdominalis in one patient and with the mucoperostium of contra-lateral inferior turbinate in 5 patients (13.51%). Follow-up was for 12-43 months. Recurrence has occurred in 10 patients (27.02%) in a form of recurrence of watery rhinorrhea or recurrence of meningitis or both of them. Second endoscopic trans-nasal intervention had done in 8 of them, second recurrence occurred in 3 patients. Thus the overall success rate was (91.42%). Conclusion: Endoscopic trans-nasal approach is an effective way to repair the meningeal nasal fistulas with low morbidity and mortality rate in comparison with the traditional open neurosurgery approach.
References used
Brodie H. Prophylactic Antibiotics for Post traumatic Cerebrospinal Fluid Fistulae: A Meta-analysis. Archives of Oto. 1997 July, 123(7):749-752
Charles W. Cummings, John M. Fredrickson et al. Cerebrospinal Fluid Leaks Otolaryngology—Head Neck Surgery, 2005 Mar ,2( 63): 558-563
Gacek RR, Gacek MR, et al. Adult spontaneous cerebrospinal fluid otorrhea: diagnosis and management. Am J Otol. 1999 Nov;20(6):770-6
Kevin C Welch, James Stankiewicz et al. CSF Rhinorrhea Updated: e Medicine Specialties- Otolaryngology and Facial Plastic Surgery - Nasal & Sinus Diseases . 2009 Sep 28(3):115-119
James D.Ramsden,Rogan Corbridge et al. Bilateral cerebrospinal fuid rhinorrhoea .The Journa lof Laryngology and Otology . 2000 Feb, 114(1): 137–138
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