This Italian study was a retrospective review of 110 consecutive patients who underwent repair of their CSF leak via the transnasal endoscopic approach from 2003 to 2013. All surgery was performed by the same primary surgeon and patients with a history of anterior skull base surgery due to cancer or pituitary adenoma were excluded. Diagnostic work-up included nasal endoscopy, beta2-transferrin and radiological imaging. For defects <5mm an overlay technique was used with fascia lata or mucoperiosteum from the middle turbinate. For defects >5mm the middle turbinate was used in 32 patients using bone and mucoperiosteum from the middle turbinate. In 68 patients an underlay fascia lata graft was used with autologous cartilage or bone (usually from the middle turbinate or septum) to support this. All cases also had fibrin glue and an oxidised regenerated cellulose patch. The majority of leaks were traumatic (46%) or spontaneous (41%) in nature. In terms of location of CSF leak these were frontal (42%), ethmoidal (36%) and sphenoidal (23%). Follow-up was at least two years in all patients. The overall success rate (judged by an absence clinically of any further rhinorrhea and good graft integration) was 96.4%, in keeping with much of the previously published literature. The authors concluded that the endoscopic transnasal approach is reliable, and they feel that the intrathecal fluorescein test is safe and helpful in locating the defect. They also conclude that fascia lata seemed to be the best graft available, although they did not analyse the success rates separately of different types of grafts. This is a large case series supporting transnasal endoscopic approach as the favoured choice for repair of anterior skull base CSF leaks. 

Transnasal endoscopic management of anterior cerebrospinal fluid (CSF) leak: experience from a large case series.
Borsetto D, Ciorba A, Cazzador D, et al.
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Sunil Sharma

Alder Hey Children's Hospital, UK.

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