Name: intrathecal application of a fluorescent dye for the identification of cerebrospinal fluid leaks in cochlear malformation
Uploaded: 2020-02-29T12:00:00
Description: Watch this Scientific Journal Video about Intrathecal Application of a Fluorescent Dye for the Identification of Cerebrospinal Fluid Leaks in Cochlear Malformation at JoVE.com

No funding was received.

This protocol was approved by the local ethics committee in accordance with the Helsinki Declaration (Reg. No. A2019-0214). Informed consent was obtained from all participants. In the presented case involving a child, written informed consent was obtained from both parents.
NOTE: Fluorescein is a fluorescent dye that emits green light (520-530 nm) when stimulated with blue light (of wavelength ~485 nm). It is used for visualization of the tear film in ophthalmology. Its intrathecal use is off-...

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While many reports concerning CSF leaks focus on transnasal endoscopic approaches in skull base surgery, a standardized method of visualizing CSF leaks of the temporal bone via microscopy5,6,7 is lacking. This protocol describes an adaption of existing literature reviews for use in microscopic ear surgery.
The application of fluorescein has been described as a safe method in skull base surgery and use...

CSF leaks can be caused by trauma, preexist congenitally, or appear spontaneously. Clinically, they appear via otoliquorrhea or rhinoliquorrhea and can be confirmed by positive &#946;-transferrin secretion1,2. In cases of CSF leaks, reliable detection of its origin is needed to seal the leak sufficiently and prevent complications, such as meningitis.
Intrathecal fluorescein application (IFA) has been known to be highly sensitive in detecting CSF leaks after neurosurgical skull base operations3. However, there is no common consensus on its exact applications (e.g., concentration, amount of fluid, addition of other drugs such as dexamethasone)3,4. A majority of cases describe transnasal endoscopic skull base surgery, while a standardized method of visualizing CSF leaks in the temporal bone via microscopy5,6,7 is missing. These leaks frequently occur at multiple localizations and bear the risk of recurrence if their whole extent is not visualized during surgery8. Specifically, a transmastoid approach only has been found to bear the risk of recurrent leaks8.
This protocol presents the use of intrathecal administered fluorescein via a transmastoid approach. A clinical case of bilateral congenital ear malformation (right ear: cochlear aplasia, left ear: incomplete partition type I), in which minor trauma led to perforation of the left stapes footplate in the middle ear, is also presented. A similar case has only been reported once9.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Fluorescein ALCON 10% injection solution</td>
			<td>NOVARTIS</td>
			<td>1467007</td>
			<td></td>
		</tr>
		<tr>
			<td>External lumbar drain catheter Silverline</td>
			<td>Spiegelberg</td>
			<td>ELD33.010.02</td>
			<td></td>
		</tr>
		<tr>
			<td>Otologic instruments (round knifes, hooks, curette, sickle knife, microscissors and microforceps)</td>
			<td>Spiggle und Theis</td>
			<td></td>
			<td>No further specification; instruments can vary between the clinics and their use depends on the surgeon&#39;s preferation</td>
		</tr>
		<tr>
			<td>Surgical microscope ARRISCOPE 1.0</td>
			<td>ARRI Medicals</td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr>
			<td>Consumables</td>
			<td></td>
			<td></td>
			<td>No further specification; material of the standard equipment of the operating clinic can be used</td>
		</tr>
		<tr>
			<td>Water to rinse</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Antifog solution</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cotton pads</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cottonoid pledges</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Gown</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Gloves</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Mask</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Suction tubes</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Blade</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

intrathecal application of a fluorescent dye for the identification of cerebrospinal fluid leaks in cochlear malformation

In cases of cerebrospinal fluid (CSF) leaks, reliable detection of their origins is needed to seal the leak sufficiently and prevent complications, such as meningitis. A method is presented here using intrathecal administered fluorescein in a clinical case of bilateral congenital ear malformation. A fluorescent dye is administered intrathecally to achieve intraoperative visualization of CSF leaks. The dye is applied 20 min before surgery, and concentration of 5% is used. Per every 10 kg of body weight, 0.1 mL of the fluid is applied intrathecally. The fluorescein is visualized using a fully digital microscope. The origin of the fluid leak is identified in the stapes footplate. During primary surgery, it is sealed, and cochlea implantation is performed for hearing restoration. In this specific case, 6 weeks later, the implant was explanted due to acute meningitis, and the electrode array was left as a spacer. Postoperatively, in the aural smear, &#946;-transferrin was detected. During a revision mastoidectomy, dislocated coverage of the leak was found. The stapes was removed and oval window sealed. Five days after revision surgery, no &#946;-transferrin was detected in the aural smear. During the revision of cochlea implantation 6 months later, intact coverage of the oval niche was observed. Thus, intrathecal fluorescein application proves to be a reliable tool for the detection of CSF leaks. It facilitates the orientation in malformations and complicated or unknown surgical situs. In the literature, its use is described for CSF fistulas in endonasal surgery but is rarely described in skull base and mastoid surgeries. The method has been used successfully in several cases with CSF leaks, and the results confirm the feasibility of safely accessing the origin of the leak.

In the presented case, minor trauma led to a CSF leak from the nose in a 10 month-old child. Magnetic resonance imaging (MRI) revealed a bilateral temporal bone malformation with aplasia of the right cochlea and dilation of the left cochlea and vestibule with absent interscalar septum identical to an incomplete partition type one. Accordingly, brainstem-evoked audiometry was performed (Figure 1) and confirmed bilateral deafness.
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Watch this Scientific Journal Video about Intrathecal Application of a Fluorescent Dye for the Identification of Cerebrospinal Fluid Leaks in Cochlear Malformation at JoVE.com

Intrathecal Application of a Fluorescent Dye for the Identification of Cerebrospinal Fluid Leaks in Cochlear Malformation

Intrathecally applied fluorescein is used to achieve intraoperative visualization of CSF leaks. This protocol describes a lumbar puncture, the application of 5% fluorescein, and intraoperative visualization using a fully digital microscope.

In cases of cerebrospinal fluid (CSF) leaks, reliable detection of their origins is needed to seal the leak sufficiently and prevent complications, such ...

Cerebrospinal fluid leaks can either be caused by trauma, can pre-exist congenitally, or can appear spontaneously. In cases of CSF leaks, a reliable detection of its origin is needed in order to seal the leaks efficiently, and to prevent complication such as meningitis. With this video, we aim to present a method to identify a temporal basal cerebrospinal fluid leak.The case of a child with a bilateral temporal bone malformation was chosen in order to demonstrate how the intrathecal application of fluorescein can assist the orientation in anatomical variations or malformations, especially in temporal bone surgery, where a precise work, and also a good knowledge about the anatomical structures, is mandatory. The safety can be increased to a large extent by applying this method. This video protocol was approved by the local Ethics Committee in accordance with the Helsinki declaration.Informed consent was obtained from all the participants.Protocol. Preparation for surgery. Make sure to obtain audiological testing, high-resolution computer tomography, and MRI of the skull base.Obtain written informed consent about the off-label use of fluorescein. In a first step in preparation for surgery, perform lumbar puncture and place a lumbar drain for later application of the dye. Use fluorescein sodium with a 10%concentration.For lumbar application, dilute the fluorescein to a 5%concentration with aqua. Apply 0.1 milliliter of the dilution per each 10 kilograms of body weight, with a maximum of one milliliter intrathecally. Perform the application immediately before surgery in order to achieve intraoperative visualization.When applying the method in children, the application should be performed in general anesthesia. General anesthesia is performed according to the patient's individual clinical history and risk factors according to the decision of the anesthesiologist. Cover the microscope with a blue light filter to visualize the fluorescein, or use a fully digital microscope.Use sterile draping to cover the patient.Surgery. For the transmastoid approach, perform mastoidectomy and posterior tympanotomy. Expand the surgery according to the expected origin of the leak.As a first land mark, expose the dura to the middle cranial fossa. Thin out the posterior canal wall of the outer ear canal. Expose the short incus process in the antrum, and identify the lateral semicircular canal.As the next surgical step, expose the chorda facial angle, where the chorda tympani leaves the facial nerve. Open the facial recess. Leave the facial nerve with a bony coverage.Access the middle ear through posterior tympanotomy. The origin of the fluid leak can easily be identified in the stapes footplate. Use fascia from the temporal muscle and absorbable collagen-fibrin sealant patches to seal the CSF leak until no more fluid leaves the footplate.The stapes superstructure is stabilizing the sealant.Results. In the presented case, minor trauma has led to a CSF leak from the nose in a ten month old child. MRI revealed bilateral temporal bone malformation, with aplasia of the right cochlea and a dilatation of the left cochlea and vestibule, with absent interscalar septum.Identical to an incomplete partition type I.Brainstem-evoked audiometry was performed and confirmed bilateral deafness. Since high-resolution computer tomography did not reveal the origin of the CSF, fluorescein assisted transmastoidal auto-basal exploration with simultaneous cochlea implantation was indicated. During primary surgery, the trans-mastoidal approach was used to identify the CSF in the stapes footplate, to seal the leak, and to perform cochlear implantation for hearing restoration.Six months after prior surgery, the child suffered from meningitis caused by mastoiditis. The implant was removed and the electrode array was left as a spacer. Postoperatively, the oral smell detected beta transferrin.Revision mastoidectomy was performed, showing a dislocated coverage of the leak in the stapes footplate. The stapes was completely removed, and the oval window was sealed using temporal muscle, temporal fascia, and absorbable collagen-fibrin sealant patches. The stapes was investigated under the electron microscope, showing the malformated footplate with perforation.In order to reduce the pressure onto the leak, lumbar puncture was performed daily. Five days after revision, no more beta transferrin was detected. During cochlear implant revision six months later, the coverage of the oval niche was intact.The presented case shows that the intrathecal application of fluorescein can be used for the intraoperative identification of auto-basal CSF leaks. It facilitates the orientation in malformations or in a complicated or unknown anatomical variation of the temporal bone. This method has been used in several of our clinical cases, and the results confirm the visibility of safely accessing the origin of the leak.

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