Patients with cerebrospinal fluid (CSF) rhinorrhea may develop life-threatening complications such as meningitis, pneumocephalus, and brain abscesses. Closure of the fistula is required to prevent these complications. A variety of techniques, including conservative management and surgery, have been reported for the treatment of CSF rhinorrhea. Recently, endoscopic endonasal closure of the fistula has been used with good results. Three patients underwent endoscopic endonasal repair procedures at Kobe University Hospital for the treatment of CSF rhinorrhea fistulas connecting the anterior skull base and the sinonasal tract. Two patients developed CSF leaks after undergoing neurosurgical procedures involving the anterior skull base. The specific sites of the leaks in these two patients were the ethmoid sinus and the sphenoid sinus. The third patient developed idiopathic CSF rhinorrhea of the cribriform plate. In all three patients, autologous grafts of their abdominal fat with fascia or the mucosal flap of the middle turbinate were used to repair the fistulas. The idiopathic CSF leak was successfully closed. However, recurrences developed in the two patients who had undergone previous neurosurgical treatment. In the patient who developed a CSF leak from the sphenoid sinus, the fistula could not visualized because of scar tissue. In the patient who developed a CSF leak from the ethmoid sinus, multiple bone defects and fistulas were found. These difficult surgical conditions are considered to be the main reasons for the unsuccessful outcome.
Three adeolescent cases of rhinogenic intracranial complications are reported. Case#1 was an 11-year-old girl diagnosed with a rhinogenic subdural and extradural abscess. Case#2 was a 15-year-old girl diagnosed with a rhinogenic subdural abscess and bacterial meningitis. Case#3 was a 13-year-old boy diagnosed with a rhinogenic subdural abscess and bacterial meningitis. All three cases were successfully treated using broad-spectrum antibiotics, sinus surgery and neurosurgical drainage. Streptococcus intermedius was identified in all three cases. The development of antibiotic therapy and sinus surgery is thought to have reduced postoperative intracranial complications. Recent reports suppose that idiopathic frontal sinusitis is the most frequent cause of intracranial complications. The development of antibiotic therapy would have been reducing intracranial complications. Relatively speaking, the idiopathic cases are increasing, and the postoperative cases are decreasing due to the development of sinus surgery. Idiopathic frontal sinusitis was the cause of the intracranial complications in all of the presently reported cases. The paranasal sinuses were fully developed in all three patients, and they experienced fewer nasal symptoms than usual. Subdural abscesses are rare, and sinusitis is thought to be the major cause of this disease. Therefore, a complete examination should be performed in cases with frontal sinusitis and neurological symptoms, such as headache or fever, to rule out the possibility of intracranial complications. Magnetic resonance imaging is more useful than computed tomography for the early detection of intracranial lesions.
Primary mucocele of the ethmoid sinus is relatively rare. Since computed tomography (CT) and magnetic resonance imaging (MRI) provide precise diagnosis, untreated cases with clinical symptoms are rare. We treated an 84-year-old woman with a primary cyst of the anterior ethmoid sinus that induced severe global displacement on the right side. She has not consulted medical doctors during the 6 years she had the cyst because she had no symptoms such as double vision, visual disturbance, or orbital pain. She did not notice double vision because simultaneous perception had probably been disturbed already due to strabismus. The posterior ethmoid sinus and the sphenoid sinus consisted of several occulsive lesions containing effusion, although none were expansive. One of the posterior ethmoid cells demonstrated an anatomical variant called the Onodi cell. We exteriorized both cyst and occulsive lesions under an endonasal approach using an endoscope, treating the lesion adjacent to the optic nerve (Onodi cell). Yellowish effusion was drained from cyst, and Streptococcus intermedius and Streptococcus sanguis were isolated but lesion mucosa did not appear inflamed. A small lesion found in the sphenoid sinus after surgery had disappeared spontaneously by the time we examined it with CT 1 year later. Some difficulties were indicated in techniques to remove lesions completely in the complex sinus structure as seen in the present case, even using an endoscope. The Onodi cell is recognized as an important variant. Surgeons are cautioned not to be disoriented and injure the optic nerve or carotid artery during endoscopic sinus surgery. It is unknown whether the peculiar structure of the Onodi cell contributes to pathogenesis of an occlusive lesion. Such possibility was not indicated in our case.
Several important structures, such as the carotid artery, oculomotor nerve, trochlear nerve, abducent nerve and trigeminal nerve are located in the cavernous sinus. This sinus is also in contact with the lateral wall of the sphenoidal sinus, and various lesions arising in the sphenoidal sinus extend beyond its confines, giving rise to diplopia and visual disturbances. Between October 1995 and February 2001, we experienced 7 cases of cavernous sinus involvement: 2 cases of sphenoidal sinusitis, one case of sphenoidal mucocele, two case of sphenoidal carcinoma, and two cases of nasopharyngeal carcinoma. These cases were analyzed, and the regional anatomies and variety of lesions are reported.
From 1993 to 2002, 74 patients with epitaxis were hospitalized at our department. 37 patients could not be controlled by conventional packing method. The ethmoidal arteries was ligated in 2 cases, selective catheter embolization conducted in 9 cases, and endoscopic electrocautery done in 26 cases. Epitaxis could not be controlled in 3 patients treated with selective catheter embolization. Epitaxis was successfully controlled in all patients treated with endoscopic electrocautery and no complications were encountered. Endoscopic electrocautery is thus the treatment of choice in patients whose epitaxis cannot be controlled by conventional packing.