The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
What Is the Best Method to Treat CSF Leaks Following Resection of an Acoustic Neuroma? Matthew J. Provenzano, MD; Daniel I. Choo, MD BACKGROUND While the published rates of cerebrospinal fluid (CSF) leak following acoustic neuroma resection varies, it remains a known complication. It is unclear if tumor size and surgical approach affect the risk of CSF leak postoperatively. Meticulous surgical technique during middle fossa, retrosigmoid, and translabyrinthine approaches, along with judicious use of perioperative lumbar drains, have decreased the leak rate over the previous decades. Despite these improvements, CSF leaks postresection presents a management challenge. The best method to deal with this problem remains to be proven. Optimal management would be minimally invasive, carry little morbidity, prevent unnecessary surgical procedures, and not prolong treatment with ineffective interventions. Those patients that require more invasive treatment should be identified early to prevent delay of optimal management.
LITERATURE REVIEW No randomized controlled trials exist concerning postoperative management of CSF leaks following acoustic neuroma excision. A number of retrospective studies have examined management practices. Treatment protocols can be divided into conservative options versus surgical intervention; the former consisting of elevation of the head, pressure dressings, fluid restrictions, bed rest, stool softeners, sutures placed in the surgical wound in the case of incisional leaks, and possible use of medications such as acetazolamide. The addition of acetazolamide to these protocols has not been extensively studied; optimal dosing and duration parameters are unknown. However, Becker and colleagues have the patient remain on it for 1 month after cessation of leakage.1 Lumbar drain placement is considered a
From the Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, U.S.A. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Daniel I. Choo, MD, Director, Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, ML 2018, 3333 Burnet Avenue, Cincinnati, Ohio 45229-3026. E-mail: [email protected] DOI: 10.1002/lary.24157
conservative intervention in some protocols and a secondary, invasive intervention in others. In all treatment schemes, lumbar drain placement occurs prior to returning to the operating room for a definitive surgical procedure. While some only administer a dose of antibiotics at the time of placement and do not continue prophylactic dosing while it remains in place, others will continue the antibiotics until its removal. Multiple studies have divided protocols based on the leak location: rhinorrhea versus incisional line.1–3 Mangus et al. managed incisional line leaks with placement of reinforcing sutures at the skin closure and conservative management without lumbar drainage. Treatment failures then proceeded to lumbar drain placement for 3 days. Surgical intervention was reserved for patients with a persistent leak. In their series, 91% of patients (115/126) presenting with suture line leak were treated conservatively. Only 10% of these patients required measures beyond conservative treatment.2 Eleven patients with wound leak proceeded directly to a surgical intervention. However, it is unknown if these 11 patients had only lumbar drain placement or a more invasive procedure. Two patients in this group required multiple interventions to treat the leak. A similar algorithm was followed by Becker et al. and Selesnick et. al.1,4 They reinforced the suture line and implemented conservative measures prior to placement of a lumbar drain.1,4 Persistent leaks required drain placement for 3 days. In their protocol, patients with suture line leaks that failed lumbar drain placement then received a lumbar peritoneal drain.1 It is unclear if lumbar drainage failed to ameliorate the problem in any patients. Optimal duration of lumbar drainage, regardless of leak location, remains unknown; 2 to 5 days has been suggested by some authors.4 However, there is no evidence demonstrating the optimal duration of drainage for acoustic neuroma excision. Surgical approach may also affect lumbar drain success rates. Allen et al. reported success in 90% of patients treated with lumbar drain placement after translabyrinthine approach, compared to only 50% of those who underwent suboccipital approach.5 A second treatment pathway exists for CSF rhinorrhea. Compared to suture line leaks, rhinorrhea treated with conservative management has lower success rates.4 Mangus et al. implemented conservative treatment with
Laryngoscope 124: December 2014 Provenzano and Choo: Treatment of CSF Leak Following Resection of an Acoustic Neuroma
2651
lumbar-peritoneal shunt in the wound group and obliteration in the rhinorrhea cohort. Definitive surgical intervention depends on the original approach and resection. Closures of the Eustachian tube and the external auditory canal, while often performed, have not been studied independently to determine the success in treating leaks. Attention is turned to plugging mastoid air cells, insuring adequate dural closure and prevention of leak around the internal auditory canal. Management schemes based on patient demographics, tumor size, or surgical approach have been less reliable. There continues to be conflicting information concerning the risk of leak based on tumor size.1 Some authors have divided leak risk based on surgical approach. However, subgroup analysis performed by Brennan and colleagues demonstrated that leak rate differences based on approach were negated when rhinorrhea was taken into account. While Becker and colleagues continued acetazolamide and conservative treatment 1 month after leak cessation, many authors did not.1 This is no objective evidence to support this practice, nor is there evidence demonstrating that it decreased recurrence. Fig. 1. Management scheme for CSF leak following excision of acoustic neuromas.
BEST PRACTICE lumbar drainage in only a subset of patients (17 of 120 patients) who presented with rhinorrhea; the remainder received surgical intervention. Mangus reported that only 41% of patients treated conservatively avoided surgical intervention.2 The overall surgical treatment rate for rhinorrhea patients was 92%. Of those, 18 patients required a second surgical procedure.2 Becker also differentiated patients with rhinorrhea but subdivided them into those with “sniffles” (low volume leaks) versus copious drainage.1 The former group was treated with conservative management and acetazolamide without lumbar drainage, while the latter proceeded to lumbar drainage for 3 days. Patients who failed these treatments then underwent surgical wound exploration and obliteration.1 In addition to the location of the leak, the time of onset has also been used to determine the appropriate treatment.1 Becker treated patients with onset after the fourth postoperative day differently than those who presented earlier. Previously mentioned management pertained to early onset leaks. Those patients presenting later had more aggressive treatment; wound leaks had conservative management and immediate drain placement. Late onset nasal drainage, regardless of the quantity, had drain placement and forwent a trial of acetazolamide and conservative measures. Continued drainage after 3 days of drain placement proceeded to
Leakage from suture lines should be treated conservatively with fluid restrictions, reinforcement of the suture line, bed rest, head of bed elevation, and stool softeners. Lumbar drains can be added initially or after a period of observation. Rhinorrhea, although amenable to conservative treatment, is more likely to require surgical intervention. Additional work should be conducted to determine the appropriate duration of lumbar drain placement and the role of Diamox.
LEVEL OF EVIDENCE This manuscript references five level IIB studies.
BIBLIOGRAPHY 1. Becker SS, Jackler RK, Pitts LH. Cerebrospinal fluid leak after acoustic neuroma surgery: a comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches. Otol Neurotol 2003;24:107–112. 2. Mangus BD, Rivas A, Yoo MJ, et al. Management of cerebrospinal fluid leaks after vestibular schwannoma surgery. Otol Neurotol 2011;32: 1525–1529. 3. Brennan JW, Rowed DW, Nedzelski JM, Chen JM. Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment. J Neurosurg 2001;94:217–223. 4. Selesnick SH, Liu JC, Jen A, Carew JF. Management options for cerebrospinal fluid leak after vestibular schwannoma surgery and introduction of an innovative treatment. Otol Neurotol 2004;25:580–586. 5. Allen KP, Isaacson B, Purcell P, Kutz JW, Jr., Roland PS. Lumbar subarachnoid drainage in cerebrospinal fluid leaks after lateral skull base surgery. Otol Neurotol 2011;32:1522–1524.
Laryngoscope 124: December 2014 Provenzano and Choo: Treatment of CSF Leak Following Resection of an Acoustic Neuroma
2652
Rhinological and Otological Society, Inc.
What Is the Best Method to Treat CSF Leaks Following Resection of an Acoustic Neuroma? Matthew J. Provenzano, MD; Daniel I. Choo, MD BACKGROUND While the published rates of cerebrospinal fluid (CSF) leak following acoustic neuroma resection varies, it remains a known complication. It is unclear if tumor size and surgical approach affect the risk of CSF leak postoperatively. Meticulous surgical technique during middle fossa, retrosigmoid, and translabyrinthine approaches, along with judicious use of perioperative lumbar drains, have decreased the leak rate over the previous decades. Despite these improvements, CSF leaks postresection presents a management challenge. The best method to deal with this problem remains to be proven. Optimal management would be minimally invasive, carry little morbidity, prevent unnecessary surgical procedures, and not prolong treatment with ineffective interventions. Those patients that require more invasive treatment should be identified early to prevent delay of optimal management.
LITERATURE REVIEW No randomized controlled trials exist concerning postoperative management of CSF leaks following acoustic neuroma excision. A number of retrospective studies have examined management practices. Treatment protocols can be divided into conservative options versus surgical intervention; the former consisting of elevation of the head, pressure dressings, fluid restrictions, bed rest, stool softeners, sutures placed in the surgical wound in the case of incisional leaks, and possible use of medications such as acetazolamide. The addition of acetazolamide to these protocols has not been extensively studied; optimal dosing and duration parameters are unknown. However, Becker and colleagues have the patient remain on it for 1 month after cessation of leakage.1 Lumbar drain placement is considered a
From the Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, U.S.A. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Daniel I. Choo, MD, Director, Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, ML 2018, 3333 Burnet Avenue, Cincinnati, Ohio 45229-3026. E-mail: [email protected] DOI: 10.1002/lary.24157
conservative intervention in some protocols and a secondary, invasive intervention in others. In all treatment schemes, lumbar drain placement occurs prior to returning to the operating room for a definitive surgical procedure. While some only administer a dose of antibiotics at the time of placement and do not continue prophylactic dosing while it remains in place, others will continue the antibiotics until its removal. Multiple studies have divided protocols based on the leak location: rhinorrhea versus incisional line.1–3 Mangus et al. managed incisional line leaks with placement of reinforcing sutures at the skin closure and conservative management without lumbar drainage. Treatment failures then proceeded to lumbar drain placement for 3 days. Surgical intervention was reserved for patients with a persistent leak. In their series, 91% of patients (115/126) presenting with suture line leak were treated conservatively. Only 10% of these patients required measures beyond conservative treatment.2 Eleven patients with wound leak proceeded directly to a surgical intervention. However, it is unknown if these 11 patients had only lumbar drain placement or a more invasive procedure. Two patients in this group required multiple interventions to treat the leak. A similar algorithm was followed by Becker et al. and Selesnick et. al.1,4 They reinforced the suture line and implemented conservative measures prior to placement of a lumbar drain.1,4 Persistent leaks required drain placement for 3 days. In their protocol, patients with suture line leaks that failed lumbar drain placement then received a lumbar peritoneal drain.1 It is unclear if lumbar drainage failed to ameliorate the problem in any patients. Optimal duration of lumbar drainage, regardless of leak location, remains unknown; 2 to 5 days has been suggested by some authors.4 However, there is no evidence demonstrating the optimal duration of drainage for acoustic neuroma excision. Surgical approach may also affect lumbar drain success rates. Allen et al. reported success in 90% of patients treated with lumbar drain placement after translabyrinthine approach, compared to only 50% of those who underwent suboccipital approach.5 A second treatment pathway exists for CSF rhinorrhea. Compared to suture line leaks, rhinorrhea treated with conservative management has lower success rates.4 Mangus et al. implemented conservative treatment with
Laryngoscope 124: December 2014 Provenzano and Choo: Treatment of CSF Leak Following Resection of an Acoustic Neuroma
2651
lumbar-peritoneal shunt in the wound group and obliteration in the rhinorrhea cohort. Definitive surgical intervention depends on the original approach and resection. Closures of the Eustachian tube and the external auditory canal, while often performed, have not been studied independently to determine the success in treating leaks. Attention is turned to plugging mastoid air cells, insuring adequate dural closure and prevention of leak around the internal auditory canal. Management schemes based on patient demographics, tumor size, or surgical approach have been less reliable. There continues to be conflicting information concerning the risk of leak based on tumor size.1 Some authors have divided leak risk based on surgical approach. However, subgroup analysis performed by Brennan and colleagues demonstrated that leak rate differences based on approach were negated when rhinorrhea was taken into account. While Becker and colleagues continued acetazolamide and conservative treatment 1 month after leak cessation, many authors did not.1 This is no objective evidence to support this practice, nor is there evidence demonstrating that it decreased recurrence. Fig. 1. Management scheme for CSF leak following excision of acoustic neuromas.
BEST PRACTICE lumbar drainage in only a subset of patients (17 of 120 patients) who presented with rhinorrhea; the remainder received surgical intervention. Mangus reported that only 41% of patients treated conservatively avoided surgical intervention.2 The overall surgical treatment rate for rhinorrhea patients was 92%. Of those, 18 patients required a second surgical procedure.2 Becker also differentiated patients with rhinorrhea but subdivided them into those with “sniffles” (low volume leaks) versus copious drainage.1 The former group was treated with conservative management and acetazolamide without lumbar drainage, while the latter proceeded to lumbar drainage for 3 days. Patients who failed these treatments then underwent surgical wound exploration and obliteration.1 In addition to the location of the leak, the time of onset has also been used to determine the appropriate treatment.1 Becker treated patients with onset after the fourth postoperative day differently than those who presented earlier. Previously mentioned management pertained to early onset leaks. Those patients presenting later had more aggressive treatment; wound leaks had conservative management and immediate drain placement. Late onset nasal drainage, regardless of the quantity, had drain placement and forwent a trial of acetazolamide and conservative measures. Continued drainage after 3 days of drain placement proceeded to
Leakage from suture lines should be treated conservatively with fluid restrictions, reinforcement of the suture line, bed rest, head of bed elevation, and stool softeners. Lumbar drains can be added initially or after a period of observation. Rhinorrhea, although amenable to conservative treatment, is more likely to require surgical intervention. Additional work should be conducted to determine the appropriate duration of lumbar drain placement and the role of Diamox.
LEVEL OF EVIDENCE This manuscript references five level IIB studies.
BIBLIOGRAPHY 1. Becker SS, Jackler RK, Pitts LH. Cerebrospinal fluid leak after acoustic neuroma surgery: a comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches. Otol Neurotol 2003;24:107–112. 2. Mangus BD, Rivas A, Yoo MJ, et al. Management of cerebrospinal fluid leaks after vestibular schwannoma surgery. Otol Neurotol 2011;32: 1525–1529. 3. Brennan JW, Rowed DW, Nedzelski JM, Chen JM. Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment. J Neurosurg 2001;94:217–223. 4. Selesnick SH, Liu JC, Jen A, Carew JF. Management options for cerebrospinal fluid leak after vestibular schwannoma surgery and introduction of an innovative treatment. Otol Neurotol 2004;25:580–586. 5. Allen KP, Isaacson B, Purcell P, Kutz JW, Jr., Roland PS. Lumbar subarachnoid drainage in cerebrospinal fluid leaks after lateral skull base surgery. Otol Neurotol 2011;32:1522–1524.
Laryngoscope 124: December 2014 Provenzano and Choo: Treatment of CSF Leak Following Resection of an Acoustic Neuroma
2652
