Elsevier

World Neurosurgery

Volume 93, September 2016, Pages 484.e9-484.e12
World Neurosurgery

Case Report
Basiespinal Cerebrospinal Fluid Leak as a Complication After Adenoidectomy: Case Report and Literature Review

https://doi.org/10.1016/j.wneu.2016.07.053Get rights and content

Background

Adenoidectomy is one of the most common procedures in the field of pediatric otolaryngology. Postoperative bleeding is one of the most frequent complications (0.4%). In turn, cerebrospinal fluid fistula is a very uncommon but critical complication in this type of surgery.

Methods

We report the case of a 3-year-old patient who underwent adenoidectomy and presented a cerebrospinal fluid leak associated with pneumocephalus and meningitis.

Results: The solution provided was a suture in layers of the fistula tract, reinforced with basipharyngeal vascularized and rotation random flap of mucosa, and a free graft of muscle, through a transoral endoscopic approach.

Conclusions

Cerebrospinal fluid leak as a complication after adenoidectomy is exceedingly rare. These pharyngospinal fistulae are determined by the anatomic features associated with intraoperative hemorrhagic complications, and it is essential that we take them into account when facing postoperative complications in the follow-up. The use of vascularized flaps based on the irrigation of the ascending pharyngeal artery with endoscopic techniques offers low-morbidity solutions, which are more efficient than traditional methods.

Introduction

Adenoidectomy is a highly prevalent surgery during childhood,1, 2 indicated when frequent infections or hypertrophy of the adenoid tissue affect nearby structures, such as the Eustachian tube (otitis media with effusion) and the nasopharynx (chronic nasal obstruction, obstructive sleep apnea, etc.).1, 2, 3

Several postoperative complications after adenoidectomy have been described, varying from the most frequent one—postoperative bleeding—to less frequent ones, such as infections or atlantoaxial subluxation. Postoperative bleeding usually occurs within the first 6 hours after surgery; however, it is more frequent in patients with blood dyscrasia or when surgery is performed along other procedures, such as tonsillectomy. Control of the bleeding is usually obtained by cauterizing the surgical site; however, in cases where this is not effective, a posterior nasal packing is performed.4 Even though electrocautery during adenoidectomy may substantially alter local temperature, these complications seem to be independent from the chosen adenoidectomy technique.2, 5 Considering the location of the pharyngeal tonsils, other potential complications may be described, such as damage to the nasopharyngeal ceiling or the craniocervical junction, resulting in cerebrospinal fluid (CSF) leaks; however, it is highly rare.6 CSF leaks of the skull base are usually found in lesions located between the ethmoidal bone and the second cervical vertebra7 and are usually caused by the presence of tumors, trauma, or surgery in this area. In these cases, the clinical features must be accompanied by radiologic imaging (computed tomography [CT] scan and magnetic resonance imaging [MRI]) for a complete assessment of the case. ß-trace protein is a reference marker for diagnosing CSF leaks because it is both highly sensitive (100%) and specific (91%).8

Reconstruction of small and idiopathic defects of the skull base can be reliably performed with a variety of known techniques with a high degree of success (90%–97%).9, 10 Current closing techniques based on vascularized flaps from arterial pedicles have been developed, such as the ones described by Hadad et al.11 The use of vascularized tissue flaps does not appear to be critical in these cases, but the current options available for reconstruction have expanded, and the decision to reconstruct must take into account the likely location, size, and shape of the skull base defect. However, in our case, we found a high flow fistula with direct communication between the oropharynx and the premedullary cistern.

We present an extremely rare complication and a new technique for the reconstruction of skull base defects.

Section snippets

Materials and Methods

We report the case of a 3-year-old girl, with no relevant medical history, who underwent an adenoidectomy and myringotomy with tympanostomy tube insertion for chronic adenoiditis and bilateral otitis media with effusion in a different hospital. Forty-eight hours after surgery, she developed neck stiffness, lethargy, and fever symptoms, suggestive of bacterial meningitis; therefore, empirical antibiotics were administered. During the diagnosis, a CT scan was performed, which showed a severe

Discussion

When the different potential complications after adenoidectomy are analyzed (postoperative bleeding, infection, etc.), CSF leaks are not contemplated in the current diagnostic protocols because they are extremely rare. When the patient presented the active flow of CSF through the nasal cavities and the oropharynx associated with deterioration of her general condition, the possibility was considered. Approximately 80% of CSF rhinorrhea cases are caused by cranial trauma, whereas 16% are

Conclusions

Postadenoidectomy complications are not usually severe and can often be solved with nonaggressive measures. The CSF leak is an extremely rare complication after an adenoidectomy for which we have described a new technique for the reconstruction of skull base defects. This kind of pharyngospinal fistulae may occur, depending on the specific anatomic features of each patient, associated with the different attitudes toward intraoperative bleeding complications, as shown in this case, making its

Acknowledgments

The authors thank all participants who voluntarily embarked in this project. The authors also thank the Anesthesiology Department and the Nurse Department of the University Hospital of Virgen del Rocío and Macarena for their excellent technical assistance.

References (13)

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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