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Peter D. Costantino, MD; David H. Hiltzik; Chandranath Sen, MD; Craig D. Friedman, MD; John F. Kveton, MD; Carl F. Snyderman, MD; Alexander R. Gnoy, MD

Arch Otolaryngol Head Neck Surg. 2001;127:588-593.

Despite advances in neurological, reconstructive, and endoscopic sinus surgery, sphenoethmoid cerebrospinal fluid (CSF) fistulae continually pose difficult management problems. Standard surgical techniques for fistulae closure succeed approximately 78% to 90% of the time. To improve this success rate, hydroxyapatite cement (HAC), a Food and Drug Administration–approved substance for cranial defect repair, was applied to this problem in a clinical setting. Twenty-one patients with spontaneous, posttraumatic, or postoperative CSF leaks of the sphenoid sinus, cribriform plate, or ethmoid region were treated with HAC. Study participants were prospectively accrued at 5 tertiary care medical centers in the eastern United States. The CSF leaks of all 21 patients treated with HAC were successfully sealed by its initial application. The sites of CSF leakage included the nasal cavity (n = 2) and sphenoid sinus (n = 19). Fifteen of the patients had previously undergone a failed repair by standard methods. There have been no recurrent CSF leaks with a maximum follow-up of 72 months, and an average follow-up of 36 months. All patients have survived to date. The only HAC-related morbidity was the extrusion of the HAC when placed in the nasal cavity. Hydroxyapatite cement is an effective method of repair for postoperative, posttraumatic, and spontaneous sphenoid CSF leaks. The efficacy of HAC in sealing the CSF leak was unaffected by previous attempts at leak closure by standard methods or by its origin. Hydroxyapatite cement should not be applied transnasally for the treatment of an ethmoid region fistula owing to its high probability of extrusion. Correct patient selection and technical familiarity with HAC are necessary for successful application.

From the Center for Cranial Base Surgery, St Luke's–Roosevelt Hospital (Drs Costantino and Sen), the Department of Otolaryngology–Head and Neck Surgery, Columbia University College of Physicians and Surgeons (Drs Costantino and Sen), and Department of Otolaryngology, Mount Sinai School of Medicine (Mr Hiltzik), New York, NY; Center for Facial Plastic Surgery, Philadelphia, Pa (Dr Friedman); Department of Otolaryngology, Yale University School of Medicine, New Haven, Conn (Dr Kveton); and Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa (Dr Snyderman). Dr Gnoy is in private otolaryngology practice in Westfield, NJ. Drs Constantino and Friedman are consultants for and receive research funding from Stryker-Leibinger.

Corresponding author: Peter D. Costantino, MD, Center for Cranial Base Surgery, St Luke's–Roosevelt Hospital Center, 425 W 59th St, 10th Floor, New York, NY 10019 (e-mail: pcostantino{at}slrhmc.org).

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