Professional Video on Endoscopic Repair of Cribriform Plate Spontaneous CSF Rhinorrhea

Hello, I am Dr. Akbar Abbas. Today, I’ll be guiding you through an endoscopic repair of Cribriform plate (an anterior skull base) cerebrospinal fluid (CSF) leak. This particular case involves a patient with a spontaneous CSF rhinorrhea.

Endoscopic repair of Cribriform plate procedure: At the beginning of the procedure, CSF was injected through a lumbar drain to visualize the leak. You can observe the fluid pouring out. Using a Freer elevator, we reflected the middle turbinate on the left side and the middle turbinate on the right side, revealing a small hole with CSF flowing out.

First, we decongested the area using a cotton patty soaked in adrenaline. This is crucial to clearly demarcate the leak site and to prevent excessive oozing during the procedure. Remember, the total volume of CSF is about 150 ml, so it’s important to quickly identify the leak before the CSF runs out.

In this case, the patient, a lady with a high BMI and idiopathic intracranial hypertension, had a very thin skull base. This condition makes the skull base fragile due to excessive intracranial pressure. We carefully removed the mucosa from the site of the leak and the adjacent septum using a U-knife. This step is essential to ensure that the subsequent graft adheres properly to the bone.

The graft, harvested from the patient’s fascia lata, needs a clear, mucosa-free surface to stick effectively. Despite some bleeding, we gently proceeded to prepare the area, avoiding any additional damage to the thin skull base.

Once the mucosa was removed, we used a fascia lata graft to close the leak. We carefully inserted the graft into the leak site, using a pointed instrument to gently push it in. To manage oozing and maintain a clear view, we used neuropatties impregnated with adrenaline.

For this procedure, we utilized a 0° Hopkins rod. Preoperative imaging did not show a positive CSF leak on CT cisternography, but there was a significant clinical CSF leak, warranting endoscopic repair.

As the graft was positioned, we ensured it plugged the leak completely. After the initial layer of the graft was in place, we applied a sealant to stop any remaining oozing. It’s crucial to apply the sealant to a dry area with no excessive bleeding.

Finally, we added a second layer of closure using another fascia lata graft. We applied more sealant on top of this second layer, allowing it to consolidate for about 3-4 minutes. Instead of using permanent packing, we opted for Surgicel and gel foam to secure the repair.

Postoperatively, patients are advised to rest in bed with their heads elevated for a couple of days before discharge. They must avoid activities that increase intracranial pressure, such as heavy lifting and straining during bowel movements.

Thank you for joining me in this detailed walkthrough of the endoscopic repair of a cribriform plate spontaneous CSF rhinorrhea. You can also watch other relevant video here.

This educational video allows students and patients to make informed decisions about their own and others’ health. Dr Akbar Abbas is a leading figure in ENT surgery within Pakistan, offering hope and expertise to countless patients facing similar challenges. He specializes in otolaryngology, cochlear implants, and ear surgery and is one of the few experts on pituitary and head and neck cancer surgery in Pakistan. Presently serving at Aga Khan University.