Ballengers

Manual of
Otorhinolaryngology
Head and Neck
Surgery
James B. Snow Jr, MD

Professor Emeritus,
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Former Director,
National Institute of Deafness and
other Communicative Disorders,
National Institutes of Health
Bethesda, Maryland
2002
BC Decker
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Printed in Spain

24
ACUTE AND CHRONIC
NASAL DISORDERS
Valerie J. Lund, MS, FRCS, FRCS(Ed)
Page 276-291
INFECTIOUS RHINITIS

Infectious rhinitis or rhinosinusitis, which better describes

the pathophysiology, may be attributable to a long list of
causative agents. These include viruses, bacteria, fungi, protozoa,
and parasites. A number of congenital conditions may predispose

patients to infection of the respiratory tract, including

PCD, cystic fibrosis, and immune deficiency. The most common
cause of infection in the upper respiratory tract is the
common cold, caused by over 100 different types of rhinovirus.
Most young adults suffer from two to three colds each year, and
it is estimated that 0.5 to 2% of these will become bacterially
infected. The virus is normally transported into the nose by
direct contact with the fingers rather than by airborne contamination,
and once the virus gains access to the respiratory
epithelium, it will produce ciliary stasis and destruction. After
1 to 3 days incubation, a prodromal or dry phase occurs followed
by a catarrhal phase. This may be followed by resolution
or secondary bacterial infection when the discharge becomes
mucopurulent. Little other than symptomatic relief can be
offered in the form of decongestants and antipyretics. Influenza
in its various forms constitutes a more specific and potentially
serious viral respiratory tract infection, resulting in pandemics
with significant morbidity and mortality in susceptible populations.
More permanent damage to both ciliated and olfactory
epithelium may result, and although vaccines are available,
their usefulness is limited by the potential for viral mutation.
Etiologic Factors
A number of congenital conditions may predispose patients
to infection of the respiratory tract.

25
SINUSITIS AND POLYPOSIS
Andrew P. Lane, MD
David W. Kennedy, MD
276

PATHOPHYSIOLOGY OF RHINOSINUSITIS

Rinosinusitis merupakan kelainan yang paling umum terjadi dan memiliki dampak yang signifikan
pada kualitas hidup individu dan meyebabkan beban ekonomi yang besar di Amerika secara
keseluruhan. Penyebab utama RSA banyak dan termasuk variasu host dan faktor lingkungan. Pada
akhirnya walaubagaimanapun, secara umum terjadinya RSA adanya bakteri pada sinus dengan
obstruksi ostium. Hal ini tidak hanya menghambat aliran anatomi normal sinus, namun juga
kegagalan fungsi klirens mukosilier dari mukosa yang biasanya akan mengeluarkan bakteri.
Obstruksi ostium yang reversibel dapat menyebabkan infeksi virus saluran nafas atas, alergi,
iritasi, barotrauma. Sumbatan ireversibel disebabkan oleh anatomi yang sudah terbentuk,
berkontribusi terhadap sumbatan atau merupakan penyebab satu-satunya. Ostium menjadi
tersumbat, hipoksia lokal terjadi pada sinus dan terjadi akumulasi sekret sinus. Kombinasi dari
tekanan oksigen yang rendah dan media kultur yang kaya akan sekresi ini menyebabkan
pertumbuhan bakteri. Silia epitel yang abnormal atau kualitas atau kuantitas dari mukus
menghalangi pengeluaran bakteri. Penyakit sistemik immunocompromised merupakan potensi
predisposisi pasien RSA. Penyakit kronik, seperti diabetes atau malnutrisi, gangguan metabolik,
kemoterapi, terapi lama kortikosteroid, akan bertendensi meningkatkan sinusitis akut. Rinosinusitis
selama 12 minggu diklasifikasikan sebagai rinosinusitis kronik. Patofisiologi yang mendasari
sinusitis kronik semestinya bukan infeksi dan sering merupakan proses inflamasi yang berlangsung
sendiri. Sedankan sinusitis akut secara histologi merupakan proses eksudatif dikarakteristikan oleh
infiltrasi neutrofil dan nekrosis, sinusitis kronik merupakan proses proliferasi yang menyebabkan
penebalan mukosa. Infiltrasi sel yang utama pada sinusitis kronik adalah eosinofil, pada pasien
alergi dan non alergi. Terdapat tanda yang berpengaruh There is evidence that potent
eosinophil-attracting chemokines diproduksi pada mukosa sinus, dikembangkan oleh variasi
tipe sel dibawah stimulasi sitokin memproduksi sel T dalam jumlah besar. Peningkatan level
interleukin-4 dan interleukin-5 pada sinonasal menaikkan migrasi dan memperpanjang waktu
kehidupan eosinofil. Jumlah proinflammatory cytokines diregulasi dan keterlibatan dalam proses
are up-regulated and participate in the process of directing lymphocyte and
granulocyte traffic while causing further production of cytokines in an autocrine
fashion. Degranulasi eosinofil melepaskan enzim destruktif yang merusak epitel. Hal ini

mengganggu fungsi pertahanan normal dan aktivitas mukosilier dari mukosa, menyebabkan
bakteri dan jamur membentuk koloni pada kavitas sinus. Kerusakan epitel mengiritasi ujung saraf
sensori, menyebabkan nyeri dan menstimulasi perubahan sekresi mukus dan permeabilitas endotel
melalui reflex pathways.
COMPLICATIONS OF RHINOSINUSITIS
Komplikasi sinusitis dapat dibagi The complications of sinusitis can be divided broadly into
those involving the orbits and those that involve the intracranial
space. In the antibiotic era, such complications have
become less commonplace, but they still have the potential for serious morbidity or even mortality.
Awareness and early
recognition of complications are necessary to minimize
adverse sequelae. Fortunately, improved diagnostic modalities
and advances in medical and surgical techniques have
significantly reduced the risk of blindness or life-threatening
intracranial infections. Ethmoiditis most commonly leads to
orbital involvement, followed by infections of the maxillary,
frontal, and sphenoid sinuses. Infections of the ethmoid can
directly erode the thin lamina papyracea or extend through
suture lines or foramina into the orbit. Intracranial complications
of sinusitis occur less frequently than orbital complications
but are potentially life-threatening if not recognized and
treated. Most intracranial infections arise from the frontal
sinus, although extension from the other sinuses is possible.
The most frequent route of spread is retrograde thrombophlebitis
via valveless veins in the posterior table of the
frontal sinus that communicate directly with dural veins. The
types of complications that may develop include osteomyelitis
of the frontal bone, meningitis, epidural abscess,
subdural empyema, and intracerebral abscess. Potts puffy
tumor is a well-circumscribed swelling of the forehead
caused by anterior extension of frontal sinusitis. The edema
of the skin and soft tissue overlies a collection of pus under
the periosteum of the anterior table of the frontal sinus.
In cases of orbital complications, the decision to proceed
to surgery is made based on a number of factors and is individualized
to the particular patient. Progressive visual loss
demands aggressive management and drainage of the source
of infection. Surgical intervention should be considered when
there is disease progression after 24 hours of antibiotics or no
improvement after 2 to 3 days of therapy. Ideally, surgery
involves approaching both the orbital complication and
underlying sinusitis simultaneously. The mainstay of therapy
for suspected intracranial complications is intravenous antibiotics
capable of crossing the blood-brain barrier. If cultures can be obtained from the affected sinuses,
this will guide specific
antibiotic choice. A neurosurgical consultation is sought
when a procedure may be necessary to drain an intracranial
collection. Corticosteroids are usually not used during an
active infectious process; however, they are sometimes
employed to reduce severe brain edema. Surgery should be
directed at the involved sinuses as well as the intracranial
process unless the patients condition limits operative time, in
which case, the neurosurgical procedure takes precedence.

DIAGNOSIS OF RHINOSINUSITIS

The most common complaints associated with rhinosinusitis

are nasal obstruction and nasal congestion. These sensations
likely result from the thickening of the sinus and nasal
mucosa, along with reactive swelling of the inferior and middle
turbinates. Postnasal discharge is also a common symptom
reported by sinusitis patients. These symptoms, which largely
reflect inflammation of the nasal cavities, are present in allergies
and colds as well as sinusitis. Facial pain, pressure, or
fullness can be a more localizing symptom of sinus disease
that may help in its identification. Particularly in acute sinusitis,

pain over the maxillary or frontal regions can be a prominent

feature in the patients history. Maxillary sinus pain may
also be referred to the upper teeth and palate. Ethmoid sinusitis
classically causes pain between or behind the eyes.
Sphenoid inflammation or infection tends to cause more insidious
pain that may be referred to the occipital, vertex, or
bitemporal regions of the skull. Of course, there are many
other causes of headache and dental pain besides sinusitis;
thus, facial or head pain is not a specific finding. Also, pain is
a less common finding once sinusitis becomes chronic, except
when there is an acute exacerbation. Similarly, acute sinusitis
is sometimes associated with systemic symptoms such as
malaise, fever, and lethargy, whereas chronic sinusitis typi- cally is not. A common symptom seen
in chronic disease more
often than in the acute situation is olfactory loss. Sore throat,
cough, and fatigue may be present in either case.
The external findings in sinusitis may be limited and nonspecific.
Periorbital, forehead, or cheek swelling is sometimes
apparent, and there may also be associated tenderness in these
regions to palpation or percussion. The oral cavity and
oropharynx should be examined for dental pathology and for
the presence of postnasal discharge. Anterior rhinoscopy can
reveal mucosal hyperemia and edema of the septum and inferior
turbinate. It may be possible to discern mucopurulent
discharge in this manner, although the site of origin is not
likely to be visualized. In recent years, there has been a
tremendous advance in the use of nasal endoscopes for
the diagnosis of nasal and sinus disease. Such endoscopes
may either be rigid or of a flexible fiberoptic design. With
endoscopy, the middle meatus can be seen directly, and any
purulent discharge may be traced either to the middle meatus
or sphenoethmoidal recess. A swab can then be used to obtain
this material under endoscopic control, yielding highly accurate
cultures that may direct specific antibiotic therapy.
The imaging study of choice today for rhinosinusitis is
computed tomography (CT) with fine coronal sections at the
level of the ostiomeatal complex. This technique is excellent
in assessing bony detail and thus provides an accurate road
map for endoscopic sinus surgery. It also is sensitive in
demonstrating mucosal thickening and revealing trapped
secretions within the sinus cavities. Unfortunately, the
mucosal changes seen by CT are not specific for sinusitis and
thus should be interpreted cautiously. Viral respiratory tract
infections and allergy will both cause mucosal thickening in
the absence of infectious or chronic sinusitis. Magnetic resonance
imaging is a complementary study that is more sensitive
than CT in showing soft tissue detail. It can clearly
demonstrate dural inflammation that would not be apprecia- ble by CT and shows the
communication of encephaloceles
with the intracranial space.

MEDICAL TREATMENT OF RHINOSINUSITIS

Once the diagnosis of acute sinusitis is ensured, the goal of

therapy is to prevent disease progression and the possibility of
serious sequelae. Antibiotics should be instituted for all cases
of acute sinusitis. Historically, there has been a dramatic
reduction in the incidence of complications secondary to
sinusitis since the introduction of antibiotics. The selection of
first-line antibiotics for acute sinusitis is directed by the
knowledge of the most common pathogens. The choice of a
second-line antibiotic is dependent on a number of variables
including patient allergies, dosing schedule, proven efficacy,
physician experience, and the patients previous response history,
as well as resistance patterns in the community. Betalactam
cephalosporins have long been the most common
second-line agents, although macrolides and fluoroquinones
have recently been increasing in popularity. The most relevant

pharmacokinetic parameter of beta-lactamase-resistant

antibiotics is the time above minimal inhibitory concentration,
which has been shown to correlate with efficacy. Once
antibiotics have been instituted, the duration of therapy is controversial.
Symptoms should begin to improve within 48 to
72 hours, and it is important to maintain appropriate followup
to ensure that the complete course of antibiotics is taken.
A good guideline is a 10- to 14-day course of therapy, which
can be lengthened for persistent symptoms.
A variety of therapeutic measures can augment the effectiveness
of antibiotics in the treatment of acute sinusitis. The
goal of these interventions is to restore proper nasal function
through improvement in ciliary function and reduction of
mucosal edema. Many simple, inexpensive supportive measures
are effective because they help to clear crusts and thick mucus. Examples include nasal saline
sprays, humidifiers
(warm or cool), steam, hot soup, or tea. Mucolytic agents
such as guaifenesin also are useful because they lead to thinning
of the mucus, which promotes clearance and prevents
stasis. Systemic and topical decongestants act on -adrenergic
receptors to cause vasoconstriction and reduction of
edema and are therefore appropriate to relieve nasal obstruction,
re-establish ostial patency, and ventilate the sinuses.
Antihistamines have been used empirically in patients with
sinusitis and allergy, although no studies show a clearly beneficial
role for these medications. In the setting of acute
infectious sinusitis, first-generation antihistamines may actually
be counterproductive because of their anticholinergic
side effects of mucosal dryness, crusting, and increased
mucus viscosity. Systemic corticosteroids are potent antiinflammatory
agents that reduce tissue edema and inhibit
inflammatory mediator production; thus, they can prove beneficial
in the treatment of acute sinusitis. However, since a
number of potential complications are associated with corticosteroids,
the use of corticosteroids is not widely accepted
for acute sinusitis. In general, the risk of adverse side effects
when corticosteroids are used conservatively over short,
tapered doses is minimal; therefore, these drugs are reasonable
adjunctive therapy for acute sinusitis treated primarily
with antibiotics.
In chronic sinusitis, the microorganisms primarily involved
are coagulase-positive and coagulase-negative species of
Staphylococcus and Streptococcus. Antibiotic therapy should
therefore be directed at these pathogens, although resistance
is a constant problem. The duration of antibiotic therapy in
chronic sinusitis is not clearly defined but is typically on the
order of 4 to 8 weeks. The goals of ancillary therapy for
chronic sinus disease are similar to those in the acute situation;
however, there are some important differences. When an
underlying condition such as allergy, polyposis, fungal infec- tion, or systemic disease is present,
the treatment must first be
directed toward controlling these processes. In the case of
allergic rhinosinusitis, management with antihistamines, topical
nasal corticosteroids, and immunotherapy will be of more
value than it would in an acute infection. Likewise, systemic
corticosteroids are indispensable for the treatment of polyps
and sinus inflammation caused by systemic granulomatous or
autoimmune diseases.

SURGICAL THERAPY FOR RHINOSINUSITIS

Endoscopic Sinus Surgery

The philosophy behind functional endoscopic sinus surgery
(FESS) stems from an understanding of the relationship
between the middle meatal anterior ethmoid complex, termed
the ostiomeatal unit, and the pathogenesis of maxillary and
frontal sinus disease. Messerklinger first described the surgical
principles of FESS and demonstrated that relieving the

ostiomeatal unit of obstruction and inflammation could

reverse mucosal disease within the frontal and maxillary
sinuses. Today FESS has become the standard operation for
rhinosinusitis, supplanting a variety of open procedures that
had previously been employed.
Functional endoscopic sinus surgery can be performed
under local or general anesthesia. Local anesthesia with intravenous
sedation may be preferable because sensory information
remains intact along the periorbita and skull base.
However, there has been a general tendency toward performing
more endoscopic sinus surgery under general anesthesia
in recent years.
The majority of the dissection in FESS is carried out using
a 0-degree endoscope because the angulation of the other
telescopes can be disorienting. The 30-degree endoscope is
usually required for examination and manipulation of the
maxillary sinus ostium and frontal recess.
An important principle in FESS is the preservation of
mucosa wherever technically feasible. The extent of surgery is
based on the preoperative assessment of the disease present;
however, in most cases, a sickle knife is first used to perform
an infundibulotomy, and the uncinate is removed. The bulla
ethmoidalis is then entered and removed. Depending on the
extent of disease, the posterior ethmoid may be entered
through the inferior and medial area of the basal lamella. The
skull base is most easily identified within the posterior ethmoidectomy
and serves as the superior boundary for the dissection.
The sphenoid ostium is located and, if necessary,
widened beginning inferiorly and medially. At this point, the
dissection is continued anteriorly along the skull base, with
care not to injure the anterior and posterior ethmoid arteries.
The mucosa along the skull base is also preserved. The frontal
recess is dissected only if required because manipulation of
this region can lead to stenosis of the frontal ostium. In addition,
frontal recess surgery increases the requirement for postoperative
care. Operating within the frontal recess is the most
challenging segment of the operation. Finally, the natural
ostium of the maxillary sinus is identified and enlarged.
The overall success of FESS is in large part owing to
appropriate postoperative care. The goal during this period is
to promote mucosal generation within the sinus cavities.
Systemic antibiotics are used, and their use may be prolonged
when severe, chronic inflammation is present. Patients may
be instructed to irrigate the nose with saline solution twice
daily. For the majority of patients with chronic sinusitis,
surgery alone does not result in a permanent disease resolution.
Long-term, culture-directed, systemic antibiotics and
prolonged use of topical nasal corticosteroids are frequently
required. It is critical to the ultimate success of endoscopic
sinus surgery that meticulous, sometimes aggressive, dbridement
be performed in the weeks following the procedure to
clear crusts, osteitic bone fragments, and forming scar tissue before these factors create persistent
inflammation and disease
recurrence. Endoscopic surveillance and proactive treatment
of residual disease eliminate the need for most revision
surgery and lead to long-term success.
Open Sinus Procedures
Although FESS can be used effectively for most medically
recalcitrant sinus disease, there are still occasional circumstances
under which open sinus procedures may be indicated.
Maxillary Sinus
In cases of symptomatic maxillary sinus mucoceles, antrochoanal
polyps, mycetoma, or foreign bodies not accessible
via an intranasal endoscopic approach, the traditional open
procedure has long been the Caldwell-Luc procedure. This
procedure begins with a gingivobuccal incision, made from

the second molar to the ipsilateral canine tooth. Dissection

proceeds sharply through the submucosal tissue and the maxillary
periostium down to bone. A periostial elevator is used
to raise the periosteum and overlying soft tissue superiorly to
the level of the infraorbital foramen. Once adequate exposure
is achieved, the maxillary sinus is entered through its
anterior wall superior to the roots of the canine and premolar
teeth using an osteotome or cutting bur. This approach gives
good visualization of all portions of the maxillary sinus and
allows complete removal of infectious material and masses
that would not be easily reached through a middle meatus
antrostomy. Stripping of the mucosa with forceps or curettes
is to be condemned and will result in permanent sinus dysfunction.
The most common complication of the CaldwellLuc approach is paresthesia or anesthesia of the cheek, teeth,
and gingiva secondary to traction on the infraorbital nerve.
Ethmoid Sinus
The external ethmoidectomy has been largely supplanted by the endoscopic approach; however,
there remain some situations
in which this approach may prove useful. For example,
excellent exposure may be provided externally for biopsies of
certain orbital lesions or lesions of the ethmoid or frontal
sinuses. Also, this approach may be employed for rapid and
safe access for orbital complications of acute ethmoid or frontal
sinusitis. The external ethmoidectomy incision generally
begins at the inferior margin of the medial aspect of the eyebrow,
curving gently downward midway between the medial
canthus and the anterior aspect of the nasal bones. The incision
is carried successively through the skin, subcutaneous tissues,
and periosteum, which is then elevated posteriorly. Attention is
given to protecting the trochlea and the attachment of the
medial canthal ligament during periosteal elevation. The
lacrimal sac is elevated atraumatically from the lacrimal fossa.
Dissection proceeds in the subperiosteal plane beyond the posterior
lacrimal crest, exposing the medial wall of the orbit. The
anterior ethmoid neurovascular bundle is encountered approximately
24 mm posterior to the anterior lacrimal crest. The
anterior ethmoid artery, found in the frontoethmoid suture line,
is clipped or electrocoagulated and divided. Although it is not
routinely necessary to dissect further posteriorly, the posterior
ethmoid artery will be encountered approximately 12 mm posterior
to the anterior ethmoid artery and approximately 6 mm
anterior to the optic foramen. Once the lacrimal bone, frontal
process of the maxilla, lamina papyracea, and orbital process
of frontal bone have been widely exposed, the ethmoid is
entered through the lacrimal fossa with a mallet and gouge or
drill. The lamina papyracea is taken down to allow complete
exenteration of the ethmoid cells.
Frontal Sinus
Open approaches to the frontal sinus are indicated for
chronic, complicated frontal sinusitis that has not responded
to trephination or conventional endoscopic sinus surgery.
the endoscopic approach; however, there remain some situations
in which this approach may prove useful. For example,
excellent exposure may be provided externally for biopsies of
certain orbital lesions or lesions of the ethmoid or frontal
sinuses. Also, this approach may be employed for rapid and
safe access for orbital complications of acute ethmoid or frontal
sinusitis. The external ethmoidectomy incision generally
begins at the inferior margin of the medial aspect of the eyebrow,
curving gently downward midway between the medial
canthus and the anterior aspect of the nasal bones. The incision
is carried successively through the skin, subcutaneous tissues,
and periosteum, which is then elevated posteriorly. Attention is
given to protecting the trochlea and the attachment of the
medial canthal ligament during periosteal elevation. The

lacrimal sac is elevated atraumatically from the lacrimal fossa.

Dissection proceeds in the subperiosteal plane beyond the posterior
lacrimal crest, exposing the medial wall of the orbit. The
anterior ethmoid neurovascular bundle is encountered approximately
24 mm posterior to the anterior lacrimal crest. The
anterior ethmoid artery, found in the frontoethmoid suture line,
is clipped or electrocoagulated and divided. Although it is not
routinely necessary to dissect further posteriorly, the posterior
ethmoid artery will be encountered approximately 12 mm posterior
to the anterior ethmoid artery and approximately 6 mm
anterior to the optic foramen. Once the lacrimal bone, frontal
process of the maxilla, lamina papyracea, and orbital process
of frontal bone have been widely exposed, the ethmoid is
entered through the lacrimal fossa with a mallet and gouge or
drill. The lamina papyracea is taken down to allow complete
exenteration of the ethmoid cells.
Frontal Sinus
Open approaches to the frontal sinus are indicated for
chronic, complicated frontal sinusitis that has not responded
to trephination or conventional endoscopic sinus surgery frontal sinus obliteration can be
performed through either a
gull-wing suprabrow incision or a bicoronal approach with
the incision behind the hairline. With either approach, an
oscillating saw is used to make bone cuts through the anterior
table of the frontal sinus. The bone flap, with its periosteum
attached superficially, is reflected inferiorly to expose the
sinus. To perform an obliteration successfully, it is absolutely
critical to remove all of the mucosa from within the sinus to
prevent the development of a mucocele. The frontal ostium is
occluded with pericranium or temporalis muscle to obliterate
the connection to the nasal cavity. Abdominal fat is usually
harvested through a periumbilical incision and cut to fit
snugly within the confines of the sinus. When the graft is in
place, the bone flap is replaced and fixed with small titanium
plates to recreate the normal frontal contour.
The most significant disadvantage of a frontal sinus obliteration
procedure is the loss of the ability to image the sinus
following the procedure. This can make assessment of postoperative
frontal sinus complaints difficult and delay detection
of some late complications. Magnetic resonance imaging
can differentiate fat from retained mucosa, secretions, and
infection, whereas CT merely shows opacification of the
sinus. Perioperative complications of the osteoplastic frontal
sinus obliteration procedure include hematoma, infection or
abscess of the bicoronal or abdominal wound, and dural
injury from bone cuts outside the sinus. The major long-term
complications of obliteration are pain or altered sensation,
visible bony defects, and mucocele formation.
Sphenoid Sinus
Although the sphenoid sinus is readily accessible endoscopically
through the nose, external approaches are frequently
used to achieve wider exposure for resection of masses or for
pituitary surgery. Most commonly, the open procedures
involve operating through the septum to the face of the sphe- noid. This can be accomplished via a
transnasal septoplasty
approach, an open rhinoplasty-type incision, or a sublabial
incision. The transnasal approach has become more popular
with the increased use of the endoscope; however, the technique
requires a relatively large nose unless an alar incision
is used. The external rhinoplasty incision gives unparalleled
access and visualization but has the potential to leave a
noticeable columellar scar. The sublabial approach is the one
most often employed because it is easy, leaves no nasal scars,
does not depend on nasal size, and allows the speculum to be
placed in the midline. The drawbacks involve oral contamination
of the wound and difficulties with oral incisions in

denture wearers.
The nasal complications are typically related to the septoplasty
portion of the procedure. These include septal perforation,
saddle deformity, and tip deformity. Epistaxis and
wound infection are also possible nasal problems postoperatively.
There are potentially serious neurologic and vascular
complications that may occur in sphenoid surgery since the
carotid artery and optic nerves travel in the lateral wall of the
sinus. Even if the optic nerve is not injured directly during
surgery, overpacking of the sinus with fat can cause optic chiasmal
compression and visual loss. Another possible complication
is cerebrospinal fluid leak, which should be treated
when it is recognized intraoperatively. During the postoperative
period, patients must be closely monitored for evidence
of change in mental status or signs of active bleeding. The
cause of these findings will generally be discovered through
radiologic evaluation, and proper intervention can be planned
and undertaken by the operative team.