Secondary Repair of Iatrogenic CSF Leak During Sinus Surgery in a Tertiary Care Center

Abstract

Background

Tertiary care centers often manage patients with iatrogenic CSF leaks from sinus surgeries performed elsewhere. There is little published regarding clinical presentation, patterns of injury, and guidance for management.

Objective

To analyze management of patients with iatrogenic skull base injury during sinus surgery managed in a secondary setting and review the literature regarding common management considerations.

Methods

This is a review of patients who underwent endoscopic sinus surgery at an outside facility with iatrogenic CSF leak and secondary repair at our institution between January 2009 and March 2023. The record was reviewed for clinical characteristics, medical interventions, and outcome measures.

Results

Nineteen patients were included with an average age of 54.6 years. There was a roughly even split between patients with chronic sinusitis with and without nasal polyps (n = 10, n = 9). Under half (42.1%) of skull base injuries were identified intraoperatively, all injuries occurred to the ethmoid skull base, and there was a predisposition toward right-sided injury. All patients underwent endoscopic repair with a 100% success rate. Two patients (10.5%) were started on acetazolamide postoperatively, both with a body mass index greater than 40.

Conclusions

Our findings underscore the importance of maintaining a high degree of suspicion for skull base injury as well as understanding endonasal anatomy and patient-to-patient variations. Our work adds to the literature suggesting a higher-than-suspected rate of missed skull base injury during sinus surgery. We anticipate an impending increase in iatrogenic injuries managed in the secondary setting, reflecting the trend toward sinus procedures being performed in the office setting. We recommend a thoughtful patient-specific approach toward secondary management, including evaluating for intracranial injury for suspected penetrating trauma and tailoring reconstruction to the particular defect.