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1/7. Delayed postoperative CSF rhinorrhea of intrasellar arachnoid cyst.

    CSF rhinorrhea due to a transsphenoidal approach usually follows accidental or intentional arachnoid opening. We report a patient with an intrasellar arachnoid cyst, who developed delayed onset of CSF rhinorrhea. A sixty-two-year-old man presented with bitemporal type visual field defect for the last 3 years. With the diagnosis of arachnoid cyst or Rathke's cleft cyst, based on MRI findings of intra-and supra-sellar cyst with CSF intensity, he successfully underwent transsphenoidal surgery without evidence of intra-operative CSF leakage. He developed CSF rhinorrhea one week later. This needed another operation for sellar floor repair. The pathomechanism of this delayed onset is explained as follows. Incomplete or oneway communication of subarachnoid space to cyst cavity, unrecognized during surgery, might cause delayed onset of CSF rhinorrhea. By using MRI, identification of the residual gland, which was compressed posteriorly, is useful for differentiating an arachnoid cyst from other cystic lesions. In highly suspect cases, even without evidence of intra-operative CSF leakage, peri-operative measures to prevent occurrence of postoperative CSF rhinorrhea are required.
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2/7. Cerebrospinal fluid leak and meningitis associated with nasal continuous positive airway pressure therapy.

    Clear rhinorrhea is a common symptom in patients with obstructive sleep apnea (OSA) and may worsen with continuous positive airway pressure therapy. Clear rhinorrhea can also be the presenting symptom of cerebrospinal fluid (CSF) leak, which is evidence of a communication between the subarachnoid space and the nasal cavity or sinuses. While CSF leak has been reported to occur with nasal continuous positive airway pressure (nCPAP) therapy following trauma to the skull base, its association with OSA and nCPAP therapy in the absence of trauma has not been previously described. We report two patients with OSA in whom CSF leak developed following the institution of nCPAP therapy. In one patient, the rhinorrhea was complicated by meningitis. Both patients underwent successful repair of their defects. One patient successfully restarted nCPAP therapy, while the other refused it.
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3/7. epidural abscess following frontal sinusitis--demonstration of communication by epidural contrast medium and coronal computerized tomography.

    A case of epidural abscess following sinusitis is presented with rhinorrhoea after irrigation of the abscess cavity postoperatively. Coronal computerized tomography and instillation of contrast medium through the catheter showed communication between epidural space and left frontal sinus.
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4/7. Tension pneumocephalus.

    Tension pneumocephalus occurs when intracranial air exists under pressure, resulting in neurologic deterioration. The syndrome is precluded by an extracranial-intracranial communication and a difference in extracranial-intracranial pressure with the latter being greater. Although most frequently associated with head trauma, a variety of situations, including an operative sitting position and use of nitrous oxide anesthesia, have been known to contribute to this potentially life-threatening complication. This article will address pathogenesis, assessment parameters, and medical and nursing approaches utilized to reduce and minimize further entrapment of air. A case report will be presented illustrating this condition.
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5/7. cerebrospinal fluid rhinorrhea and recurrent meningitis.

    cerebrospinal fluid rhinorrhea is the result of transdural communication between the subarachnoid space and the skull base. A transdural fistula may originate from the anterior, middle, or posterior cranial compartments. All skull-base sites of leakage potentially lead to the nasal cavity. Recurrent meningitis is commonly associated with such a direct source of bacterial contamination. Organisms associated with recurrent meningitis secondary to cerebrospinal fluid leaks are commonly found in the upper respiratory tract. We report a case of recurrent meningitis in a 5-year-old girl that highlights the problem of cerebrospinal fluid rhinorrhea, and we discuss etiology, current diagnostic techniques, and surgical management.
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6/7. Cochlear dysplasia and meningitis.

    Congenital dysplasias of the labyrinth of the inner ear are associated with varying degrees of hearing loss. There is a risk of a fistulous communication between the subarachnoid space and the middle ear cavity in some cases that present either as cerebrospinal fluid otorhinorrhea or as recurrent attacks of meningitis. The types of deformity where such a fistula is likely have not been clearly defined. The authors correlated the hearing state with the imaging assessment in 20 patients with congenital malformation of the labyrinth and, in particular, the cochlea. In addition the postmortem histologic findings from one patient with severe cochlear dysplasia who died from otogenic meningitis are described. The key to the assessment is the basal turn of the cochlea. If the basal turn is present and of normal caliber then some hearing is possible and there is no risk of a major fistula. However, if the basal turn is wider than normal or replaced by an undeveloped sac then there is anacusis and very real risk of fistula. In such cases the deformed labyrinth needs to be packed with fibrofatty tissues after just one attack of meningitis.
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7/7. Surgical treatment of cerebrospinal fluid fistulae involving lateral extension of the sphenoid sinus.

    OBJECTIVE AND IMPORTANCE: Four cases of spontaneous cerebrospinal fluid rhinorrhea caused by communication between the subarachnoid space of the middle cranial fossa and a lateral extension of the sphenoid sinus are presented. The cause and management of this unique type of cranial base defect are discussed. CLINICAL PRESENTATION: During the past 10 years, four patients referred to our institution with atraumatic cerebrospinal fluid fistulae were observed to have temporal encephaloceles (encephalomeningoceles) traversing the floor of the middle cranial fossa. Three of the patients had previously undergone unsuccessful transnasal attempts to repair their fistulae by obliteration of the sphenoid sinus. The fourth patient presented before undergoing any treatment. No patient had associated hydrocephalus or tumor. Preoperative computed tomographic cisternograms revealed that all fistulae involved a lateral extension of the sphenoid sinus into the floor of the middle cranial fossa. INTERVENTION: After definitive localization, each patient was operated on transcranially through an anterior middle cranial fossa approach with extradural and/or intradural exploration. The associated temporal encephalocele was amputated or disconnected, and the dehiscent dura and middle cranial fossa floor defect were oversewn and packed with autogenous tissue, respectively. CONCLUSION: The surgical treatment of cerebrospinal fluid rhinorrhea secondary to middle fossa encephalocele associated with lateral extension of the sphenoidal sinus differs from the surgical strategy for more medial sphenoidal fistulae. Fistulae involving a lateral extension of the sphenoid sinus require a transcranial approach for direct visualization and obliteration of the defect, whereas fistulae involving the central portion of the sinus may be successfully obliterated transsphenoidally.
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