Original Paper
ORL 2010;72:56–62
DOI: 10.1159/000275675
Frontal Sinus Cerebrospinal Fluid Leaks:
Repair in 15 Patients Using an Endoscopic
Surgical Approach
Jian-Bo Shi a, b Feng-Hong Chen a, b Qing-Ling Fu a, b Rui Xu a, b
Wei-Ping Wen a, b Wei-Jian Hou a, b Jie-Bo Guo a, b Xiang-Min Zhang a, b
Geng Xu a, b   
a
  Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, and
b
  Otorhinolaryngology Institute, Sun Yat-sen University, Guangzhou, PR China
Key Words
Cerebrospinal fluid leak ⴢ Endoscopic surgery ⴢ
Frontal sinus ⴢ Outcomes research ⴢ Complications
Abstract
Objectives: To clarify the utility of a safe and effective endo-
scopic procedure for closing frontal sinus cerebrospinal fluid
(CSF) leaks. Methods: A retrospective review of all 15 pa-
tients seen at our hospital from 2002 to 2008 whose CSF leak
originated within the frontal sinus or frontal recess. A trans-
nasal endoscopic or combined transfrontal endoscopic ap-
proach was used to repair the CSF leak. Results and Surgical
Outcomes: Four defects originated in the frontal recess and
11 involved the posterior wall of the frontal sinus. Nine pa-
tients were repaired by a direct endoscopic approach and 4
patients were repaired after widening the frontal recess en-
doscopically. Two patients were repaired using the com-
bined transfrontal and transnasal approach. The leak was
stopped in 14 cases (93%) after the first operation. One pa-
tient (7%) required a second repair 1 month after initial sur-
gery and has remained well after 27 months. Complications
included a frontal lobe abscess and a frontal sinus obstruc-
tive mucocele. These 2 patients were successfully treated
without further complications. Patient follow-up ranged
© 2010 S. Karger AG, Basel
0301–1569/10/0721–0056$26.00/0
Fax +41 61 306 12 34
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Received: August 17, 2009
Accepted after revision: January 4, 2010
Published online: March 24, 2010
from 4 to 44 months (mean 30 months). Conclusions: Most
frontal CSF leaks can be successfully closed by an endoscop-
ic surgical approach. Copyright © 2010 S. Karger AG, Basel
Introduction
Cerebrospinal fluid (CSF) rhinorrhea implies a com-
munication between the subarachnoid space and the si-
nonasal tract. Among the symptoms and/or signs of a
CSF leak, rhinorrhea is the most frequently seen [1]. The
existence of a CSF leak is a risk factor for serious central
nervous system complications, such as meningitis or
brain abscess [1, 2]. Failure to close a CSF leak by conser-
vative measures is an indication for surgical intervention.
The first transnasal endoscopic approach for sinus sur-
gery was reported in 1981 [3]. Closure of CSF leaks utiliz-
ing the endoscopic approach has been generally accepted,
because of the high success rates (between 86 and 100%)
with minimal morbidity [4–8].
The first two authors contributed equally to this article.
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Prof. Geng Xu, MD
Otorhinolaryngology Hospital, The First Affiliated Hospital
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 a b
Fig. 1. Type A. The defect (dashed circle) is
in the frontal recess or at the posterior wall
of the frontal sinus (FS) and is less than
1 cm in diameter, which can be exposed
adequately after removing the agger nasi
cell (AN) and widening the frontal recess.
A dashed rectangle shows the area of re-
section.
Frontal sinus CSF leaks are generally located at one of
two anatomic sites: (1) within the frontal recess and (2)
from a site within the posterior wall of the frontal sinus.
The optimal choice of approach depends upon the exact
anatomic site and size of the defect plus the experience
and skill of the surgeon. In this study, we aimed to clari-
fy the utility of an endoscopic approach for the repair of
frontal sinus CSF leaks by reviewing our experience using
an endoscopic approach and free grafts in 15 patients.
Materials and Methods
Retrospectively, we reviewed all 15 cases of frontal sinus CSF
leaks treated at our institution, Otorhinolaryngology Hospital,
The First Affiliated Hospital, Sun Yat-sen University, from 2002
to 2008. Data included demographics, presenting signs and symp-
toms, site of leak, surgical approaches, repair techniques, materi-
als, complications, recurrences, and clinical follow-up from 4 to
44 months (mean 30 months).
Preoperative evaluation of each patient consisted of history,
physical examination, nasal endoscopic examination, and a com-
puted tomography (CT) scan and/or magnetic resonance imaging
(MRI).
Endoscopic repair of frontal sinus CSF leaks is more challeng-
ing compared to repairing CSF leaks from other sites within the
sinonasal cavity [4–7]. Three key elements are required for suc-
cessful frontal sinus CSF leak closure: first, correct identification
of the leak site; second, wide exposure is mandatory; third, main-
tenance of frontal sinus and frontal recess patency postopera-
tively.
Careful endoscopic examination of the entire sinonasal cavity
is performed at the time of surgery. Watery fluid emanating from
the frontal recess raises the question of a frontal sinus CSF leak.
The presence of swollen mucosa and/or a focal granuloma sug-
gests an occult leak site just beneath the edematous tissue. A CSF
leak may be intermittent due to mucosal swelling or brain her-
niation which may temporarily occlude the leak. If the leak site
Surgical Repair of Frontal Sinus CSF
Leaks
was still not visible after complete examination, patients were
placed in the head-down position while the anesthetist performed
a forced expiratory Valsalva maneuver. The Valsalva maneuver
was repeated several times while the surgeon reexamined the
most likely site of the CSF leak including the cribriform plate re-
gion [9].
Dividing and classifying frontal sinus CSF leaks into three
types (A, B, and C) based on location allows the surgeon to select
the best surgical approach for adequate exposure, which is the key
to successful identification and closure of CSF leaks.
In type A, the defect is located in the frontal recess at the pos-
terior wall of the frontal sinus and is less than 1 cm in diameter.
In this location a defect can be seen and exposed adequately by a
direct transnasal endoscopic approach. In our study, 9 of the 15
patients were classified as type A (fig. 1a, b).
In type B, the defect was located in the posterior wall of the
frontal sinus, which may only be partially visible in the presence
of a well-pneumatized agger nasi cell. Adequate visualization and
complete exposure of these defects required frontal sinusotomy.
Wormald’s [10] axillary flap technique or Draf’s [11] IIa or IIb
procedure was utilized to enlarge the frontal recess. We classified
4 of 15 patients as type B (fig. 2a–c).
In type C, the defect was generally greater than 1 cm in diam-
eter with a small frontal ostium (anteroposterior dimension !6
mm) and a poorly pneumatized agger nasi cell, or the defect was
located on the lateral side of the posterior wall of the frontal sinus.
Two of 15 patients in our study required a combined transnasal
with a transfrontal endoscopic approach in order to adequately
delineate and repair the CSF leak. Reconstruction of the frontal
sinus drainage pathway was performed to avoid postoperative
stricture. The extent of an external arch incision for the transfron-
tal approach depends upon the size and location of the defect site.
Removal of approximately a 1-cm2 piece of frontal bone provided
adequate space for both the endoscope and the necessary instru-
mentation (fig. 3a, b).
Basically there are three repair techniques to close CSF leaks:
(1) the ‘sandwich’, (2) the ‘bath-plug’ and (3) the ‘strengthening’
techniques. The ‘sandwich’ technique is a multilayered method
generally used for smaller defects (!1 cm) [4]. Preparing the graft
site requires complete mucosal removal of approximately 5 mm
around the defect creating a ‘fresh’ graft bed. Our tissue choice for
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 a b c

Fig. 2. Type B. The defect (dashed circle) was located in the posterior wall of the frontal sinus (FS), which may
only be partially visible in the presence of a well-pneumatized agger nasi cell (AN). The defect was adequately
exposed after frontal sinusotomy. A dashed rectangle shows the area of resection for Draf IIa and IIb. The dashed
line shows the anteroposterior dimension of the frontal ostium.

a b

Fig. 3. Type C. The defect (dashed circle)

was generally greater than 1 cm in diam-
eter with a small frontal ostium (antero-
posterior dimension !6 mm) and a poorly
pneumatized agger nasi cell (AN), or the
defect was located on the lateral side of the
posterior wall of the frontal sinus, which
required a combined approach to repair
the CSF leak. The dashed line shows the
anteroposterior dimension of the frontal
ostium.

sealing and closing the leak site was autologous quadriceps muscle
as a free (nonpedicled) graft. After the muscle was applied a second
layer of quadriceps fascia was placed over the bony defect as an
‘overlay’ graft. Mucosa from the middle turbinate was added if ad-
ditional tissue was necessary. Fibrin glue was applied next, which
increases the adhesiveness between the muscle, fascia and mucosa.
Finally, layering of Gelfoam secures and supports the grafts in po-
sition and is supplemented with iodoform gauze packing.
The ‘bath-plug’ technique was used for defects exceeding 1 cm
in diameter. Wormald and McDonogh [9] first reported this tech-
nique in which a fascia plug is prepared that is slightly larger than
the defect and is tied with suture leaving one end extended form-
ing a ‘bath-plug’. The ‘bath-plug’ of tissue and attached suture are
manipulated through the base of the skull defect into the intra-
cranial cavity. Next, with the pull of the suture, the graft is tight-
ly pulled into place to cover the defect on the intracranial side.
The ‘strengthening’ technique was reserved for defects larger
than 2 cm. In this situation solid materials, such as titanium plate,
middle turbinate bony tissue and nasal septal cartilage or bone
are used maintaining or ‘strengthening’ the soft tissue grafts in
position.
Preserving frontal sinus patency requires extensive removal of
agger nasi cells and accessory frontal sinus cells, thereby ade-
quately exposing the frontal sinus outflow tract and frontal recess.
Mucosal preservation is essential to prevent postoperative steno-
sis. Office follow-up for the first 3 months after the surgery is ad-
vised.
Postoperative treatment included antibiotics, mannitol (to re-
duce intracranial pressure) and bed rest for 2 weeks. The patients
were restricted from nose blowing for 1 month.
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Table 1. Patient data

Patient Gender Age Etiology Site of Size, mm Follow-up Complication Approach Technique
years defect months

1 Male 17 T R PW 8⫻3.5 36 no 2 SW
2 Male 24 T L PW 12⫻5 42 frontal lobe abscess 1 SW
3 Male 22 T R FR 2.5⫻2.5 51 no 1 BP
4 Male 31 T L PW 15⫻15 40 no 3 SW
5 Male 38 T R PW 2⫻2 48 no 1 SW
6 Male 33 T L PW no record 44 no 1 SW
7 Male 39 T R PW 10⫻10 42 no 2 SW
8 Male 20 T L FR 4⫻4 45 mucocele 1 SW
9 Male 19 T L PW 15⫻5 42 no 2 SW
10a Male 48 S R PW 3⫻3 34 no 1, 3a SW
11 Male 11 T L FR 1⫻2 34 no 1 SW
12 Male 6 T L FR 3⫻2 28 no 1 SW
13 Female 38 T L PW 6⫻5 22 no 1 SW
14 Male 26 T R PW 8⫻8 14 no 2 BP
15b Male 27 T R PW 6⫻8 11 no 3 SW
R PW 5⫻5

T = Traumatic; S = spontaneous; L = left; R = right; PW = posterior wall of the frontal sinus; FR = frontal sinus recess; SW = ‘sand-
wich’ technique; BP = ‘bath-plug’ technique; 1 = direct endoscopic approach; 2 = endoscopic approach with widening of the frontal
recess; 3 = combined transfrontal and transnasal approach.
a Patient 10 had recurrent CSF leak 1 month after the first surgery and received the second surgery using a combined approach.
b
Patient 15 had 2 CSF leak sites.

Results after surgery, which was treated by incision and drainage

Fifteen patients (1 female and 14 males) underwent en-
doscopic frontal sinus CSF leak repair (table 1). Average
age at presentation was 26.6 years (range 6–48 years). All
patients presented with CSF rhinorrhea including 2 pa-
tients with meningitis. Primary etiology for the CSF leak
was trauma in 14 of 15 patients while 1 patient presented
with a spontaneous CSF leak. The frontal recess was the
leak site in 4 of 15 patients while 11 involved the poste-
rior table. Surgical repair using the transnasal approach
alone was accomplished in 13 of 15 patients. Two patients
(table  1, patient 4 and patient 15) required a combined
transnasal and transfrontal approach. Representative
photographs are shown in fig 4 for type B and fig 5 for
type C. Successful closure of the leak at first attempt was
accomplished in 14 of 15 patients (93%). One patient (ta-
ble 1, patient 10) had recurrent CSF rhinorrhea 1 month
later which was successfully repaired using a combined
approach. Thirteen patients had their leaks closed using
the ‘sandwich’ technique and 2 patients’ leaks were closed
with the ‘bath-plug’ technique. Two patients experienced
complications. A frontal lobe abscess developed 10 days
followed by a surgical frontal sinus obliteration operation
(table 1, patient 2). The second complication was a frontal
sinus obstructive mucocele, which occurred 2 months af-
ter operation. An endoscopic frontal sinusotomy success-
fully treated this patient (table 1, patient 8). Patient follow-
up ranged from 4 to 44 months (mean 30 months).
Discussion
Identifying the Sites of CSF Leak
Localizing the defect site is the most critical aspect of
this operation. Identification of a CSF leak begins with
the patient interview. A history of frontal injury associ-
ated with subsequent rhinorrhea usually narrows the
search to either the patient’s frontal sinus or recess or
both. A high-resolution CT in the axial and coronal
planes using 3-mm-fine cuts was recommended for base
of skull defects by Carrau et al. [5]. Axial views allow su-
perior visualization of the posterior wall of the frontal
sinus. Frequently a dehiscence in the frontal sinus poste-
rior table and frontal recess is seen on CT scan. However,
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Surgical Repair of Frontal Sinus CSF ORL 2010;72:56–62 59

Leaks
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a b
Fig. 4. CSF leak closure using a transnasal endoscopic approach.
a Coronal CT scan: defect in the posterior wall of the right frontal
sinus (arrow). Note the opacification in the frontal recess below
the arrow. b Surgical endoscopic view (4 mm, 0°): frontal recess
and a defect were seen after partially widening the frontal recess
using a Draf IIa procedure. The size of the defect was 8 ! 3.5 mm
(black arrow). This defect was repaired using a ‘sandwich’ tech-
small defects or linear nondisplaced fractures may be in-
visible even with a detailed CT technique. MRI is recom-
mended for a possible meningocele and/or encephalocele.
Despite a negative CT scan complete endoscopic office
examination of the nasal cavity may reveal the leak site.
A specific site of CSF leak is difficult to identify in pa-
tients with intermittent leaks. A number of surgeons ad-
vocate using fluorescein to facilitate leak localization [5,
9, 12]. Since fluorescein is not approved by the US Food
and Drug Administration for intrathecal injection due to
possible neurotoxicity and seizures we avoided this diag-
nostic modality entirely.
The anterior skull base is thoroughly scrutinized for
bony defects during surgery, including the cribriform
plate and the ethmoid sinus regions [2]. Multiple leak sites
may exist especially in trauma cases (table 1, patient 15).
An additional clue is the presence of edematous mucosa
and a granuloma in the frontal sinus itself or recess sug-
gesting the presence of a leak site beneath these edema-
tous or granulomatous tissues. Meticulous observation
and extraordinary persistence are sometimes required to
find the site of a CSF leak.
Selection of the Surgical Approach
Until recently, CSF leaks from the frontal sinus were al-
ways repaired either by an intracranial or an external
transfrontal approach. The surgical options changed with
the development of modern endoscopes. The transnasal
endoscopic approach to close frontal sinus CSF leaks has
been reported by Lee et al. [2] in 3 patients and by Wood-
worth et al. [12] in 6 patients with a high success rate. How-
60 ORL 2010;72:56–62
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c
nique with a free quadriceps muscle and fascia graft. A suprabul-
lar cell (white arrow) is noted adjacent to the suction. FS = Frontal
sinus. c Endoscopic view (4 mm, 0°) 1 month postoperatively:
frontal sinus (FS) outflow tract and frontal recess are widely pat-
ent. The skull base is well healed (arrow). LP = Lamina papyracea
of ethmoid.
ever, the endoscopic approach is not ideal for all frontal
sinus CSF leaks. Defects located at an extreme superior or
lateral location restrict the ability of the surgeon to reach to
defect site. In these situations an external transfrontal ap-
proach is still indispensable. The selection of an approach
depends upon the site and size of the defect, the anatomic
variants of the frontal sinus and recess, availability of des-
ignated equipment and the ability of the surgeon. The en-
doscopic modified Lothrop procedure allows adequate
manipulation at the posterior table of the frontal sinus.
This approach is particularly suitable for bilateral frontal
CSF leaks or a leak in the middle of the frontal sinus.
Based on our experience, a classification of frontal si-
nus CSF leaks became apparent and fell into four catego-
ries depending upon the site and size of the defects and
the variants of frontal sinus anatomy:
Approach 1. Requiring minimal exposure, the direct
transnasal endoscopic approach is least traumatic and
adequate for the required exposure of the leak site (fig. 4).
Approach 2. Requiring additional exposure, the Wor-
mald [10] approach (axillary flap technique) and the Draf
[11] type IIa or IIb procedure should be considered for
adequate exposure of the leak site.
Approach 3. Requiring extensive exposure, this situa-
tion combines the endoscopic transfrontal sinus ap-
proach with the transnasal approach for adequate expo-
sure of the leak site (fig. 5).
Graft Materials and Technique
Wigand [3] pioneered the use of free tissue grafts to
close CSF leaks during endoscopic sinus surgery. Today
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a b
c d
Fig. 5. CSF leak closure using a combined transfrontal and trans-
nasal approach. a Sagittal CT scan: a defect in the junction of the
posterior table of the right frontal sinus and suprabullar cell (ar-
row). b Horizontal (axial) CT scan: defect at the junction of the
posterior wall of the right frontal sinus and suprabullar cell (ar-
row). c Surgical endoscopic view (4 mm, 70°) using the transnasal
approach. A patent frontal sinus (FS) with edematous mucosa at
the junction of the posterior wall of the right frontal sinus and the
suprabullar cell. Invisible defect (black arrow). Posterior wall of
free tissue grafts are widely used with successful closures
ranging from 83 to 94% [4]. After a retrospective review
of 95 CSF leak patients from various sites with various
types of surgical repair, Gassner et al. [8] discouraged the
use of mucosal advancement flaps since there was a 83.3%
failure rate. The mean time interval between unsuccess-
ful surgery and recurrence was over 4 years (50.8 months).
These authors from the Mayo Clinic recommended the
use of free grafts, which had the lowest leak recurrence
rate at 15.6%. In our study, we also preferred free grafts
using quadriceps muscle, quadriceps fascia and turbinate
mucosa (if necessary) as our tissues of choice. Our first
attempt success rate was 93%, and 100% at second at-
tempt (mean follow-up of 30 months). These rates of suc-
cess compare extremely well with the literature [2, 9].
Surgical Repair of Frontal Sinus CSF
Leaks
Color version available online
e
the frontal sinus (white arrow). d Surgical endoscopic view (4 mm,
0°) using the transfrontal approach: a granuloma (black arrow) at
the transition of the posterior wall of the right frontal sinus and a
suprabullar cell. Posterior wall of the frontal sinus (white arrow).
FR = Frontal recess. e Surgical endoscopic view (4 mm, 0°) using
the transfrontal approach: a 3 ! 3 mm defect seen (black arrow)
after removal of the granuloma. Posterior wall of the frontal sinus
(white arrow). O = Roof of orbit.
Most techniques yield similar results in experienced
hands, which has been confirmed by a meta-analysis de-
tailed by Hegazy et al. [4].
Complications
Complication rates for meningitis (0.3%), brain ab-
scess (0.9%), subdural hematoma (0.3%), olfactory disor-
ders (0.6%), and headache (0.3%) have been well docu-
mented [4]. The frontal recess is a narrow isthmus-like
structure with a high potential for postoperative stricture
and obstruction. Two patients, early in our study, devel-
oped complications. A frontal lobe abscess occurred in 1
patient and a frontal sinus obstructing mucocele devel-
oped in the second patient. The mucocele was, in all like-
lihood, secondary to intraoperative mucosal injury. With
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meticulous mucosal preservation we avoided another ob- On the other hand, we do suggest a lumbar drain for
structive mucocele thus far. Some surgeons stent the spontaneous CSF leaks and defects associated with me-
frontal recess with plastic material to maintain its paten- ningocele and encephalocele. In our study, the patient
cy with satisfactory results [12]. who failed first-time repair had a spontaneous CSF leak.

Lumbar Drain
A lumbar spinal drain reduces CSF pressure main-
taining graft placement, which in turn facilitates healing.
The precise indication for a lumbar drain is not clear in
the literature and its usage varies from 0 to 100% [2, 4, 5,
12, 13]. Lee et al. [2] and Woodworth et al. [12] consider
the presence of a frontal sinus CSF leak as an important
indication for a lumbar drain. Hegazy et al. [4] recom-
mend a lumbar drain in patients with a post-traumatic
CSF leak. In our opinion, because of the risk of complica-
tions, such as meningitis, pneumocephalus and transten-
torial herniation we avoided the use of a lumbar drain
even in patients with traumatic frontal sinus CSF leaks.
Conclusion
In our series, most frontal sinus CSF leaks can be suc-
cessfully repaired using autogenous ‘free’ tissue grafts ap-
plied by a transnasal endoscopic approach alone (14 of 15
cases) or combined with an external endoscopic trans-
frontal approach (1 of 15 cases). We achieved a high suc-
cess rate at the first operation (14 of 15 patients, 93%) and
low complication rate (2 of 15 patients, 13.3%). Although
the external transfrontal approach is still indicated when
the leak site is beyond the reach of the endoscope, it was
not required in any of our 15 cases.

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