title: Sphenoethmoid cerebrospinal fluid leak repair with hydroxyapatite cement.
abstract: Despite advances in neurological, reconstructive, and endoscopic sinus surgery, sphenoethmoid cerebrospinal fluid (CSF) fistulae continually pose difficult management problems. Standard surgical techniques for fistulae closure succeed approximately 78% to 90% of the time. To improve this success rate, hydroxyapatite cement (HAC), a Food and Drug Administration-approved substance for cranial defect repair, was applied to this problem in a clinical setting. Twenty-one patients with spontaneous, posttraumatic, or postoperative CSF leaks of the sphenoid sinus, cribriform plate, or ethmoid region were treated with HAC. Study participants were prospectively accrued at 5 tertiary care medical centers in the eastern United States. The CSF leaks of all 21 patients treated with HAC were successfully sealed by its initial application. The sites of CSF leakage included the nasal cavity (n = 2) and sphenoid sinus (n = 19). Fifteen of the patients had previously undergone a failed repair by standard methods. There have been no recurrent CSF leaks with a maximum follow-up of 72 months, and an average follow-up of 36 months. All patients have survived to date. The only HAC-related morbidity was the extrusion of the HAC when placed in the nasal cavity. Hydroxyapatite cement is an effective method of repair for postoperative, posttraumatic, and spontaneous sphenoid CSF leaks. The efficacy of HAC in sealing the CSF leak was unaffected by previous attempts at leak closure by standard methods or by its origin. Hydroxyapatite cement should not be applied transnasally for the treatment of an ethmoid region fistula owing to its high probability of extrusion. Correct patient selection and technical familiarity with HAC are necessary for successful application.
authors.affiliation: Center for Cranial Base Surgery, St Luke's-Roosevelt Hospital Center, New York, NY 10019, USA. pcostantino@slrhmc.org
authors.forename: P D
authors.initials: PD
authors.lastname: Costantino
authors.forename: D H
authors.initials: DH
authors.lastname: Hiltzik
authors.forename: C
authors.initials: C
authors.lastname: Sen
authors.forename: C D
authors.initials: CD
authors.lastname: Friedman
authors.forename: J F
authors.initials: JF
authors.lastname: Kveton
authors.forename: C F
authors.initials: CF
authors.lastname: Snyderman
authors.forename: A R
authors.initials: AR
authors.lastname: Gnoy
mesh_terms: D002559:Cerebrospinal Fluid Rhinorrhea / Q000628:therapy*; D005005:Ethmoid Sinus; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006882:Hydroxyapatites / Q000627:therapeutic use*; D008875:Middle Aged; D011446:Prospective Studies; D013101:Sphenoid Sinus; D014014:Tissue Adhesives / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D006882:Hydroxyapatites; D014014:Tissue Adhesives