Introduction: High flow Cerebrospinal fluid (CSF ) leaks secondary to orbital apex and middle fossa leaks are life threatening and complex to repair. The most common etiologies are trauma and complications after orbital exenteration. Most reports conclude conservative management results in resolution. Those associated with large dural defects are most commonly repaired with open temporalis muscle or free flaps. We describe a unique endoscopic technique for repair of a life threatening high flow orbital apex/middle fossa csf leak.

Methods: Literature review using Ovid Medline, with focus on key words: orbital exenteration, oculorrhea, orbital CSF leak and repair. Results of the search consisted of case reports and case series, identifying orbital CSF leaks in the context of trauma, and tumor excision from the orbit. Retrospective review of a patient 2 years after orbital exenteration and radiation for squamous cell carcinoma who developed multi-organism meningitis secondary to a large high-flow orbital apex/middle fossa csf leak.. Repair technique: combined endoscopic transorbital/endonasal approach, pedicled nasospetal flap and dermis fat graft.

Results: Cisternogram post-operatively and clinical exam confirmed resolution. Stages of healing (as seen in figures 1-4) illustrate effectiveness of the flap. A critically ill patient ,modified rankin score (MRS) 5 upon admission ,was able to discharge home on continued IV antibiotic therapy with a MRS of 3.

Conclusions: This Is the first case to describe a combined endoscopic transorbital and endonasal repair of high flow orbital apex/middle fossa CSF leak with a nasoseptal flap. These techniques can be utilized during initial reconstruction after orbital exenteration or as a salvage flap. The principles and technique described transcends this particular case and is applicable to other skull base defects.

Patient Care: CSF leaks are life threatening. They occur commonly. Neurosurgeons, otolaryngologists, oculoplastic and plastic surgeons are faced with the challenges of successful repair. This case illustrates the life threatening complications that can occur with a csf leak and how important the initial decision regarding repair technique is to patient care and outcome. My research in a cadaver simulated environment will lead to improvement on current techniques and the development of new ones. Teaching these techniques in a hands on cadaver simulated model will improve patient outcomes because their treating physicians will have gained more experience thereby minimizing complications.

Learning Objectives: Literature review: etiology and repair techniques of orbital/middle fossa CSF leaks Describe the principles of successful repair of large high flow csf leaks Describe the combined endoscopic transorbital/endonasal repair technique

References: Eloy et al Salvage endoscopic nasoseptal flap repair of persistent cerebrospinal fluid leak after open skull base surgery American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 735–740 Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endo- nasal approaches: vascular pedicle nasoseptal flap. Lar- yngoscope 2006;116:1882–1886 Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000;110: 1166–1172 Salame et al Diagnosis and management of posttraumatic oculorrhea. Neuro Surg Focus 9(1) 2000; 1-4 Massoud VA, Fay A, Yoon MK.Cerebrospinal fluid leak as a complication of oculoplastic surgery.Semin Ophthalmol. 2014 Sep-Nov;29(5-6):440-9. Sayed et al Endoscopic Reconstruction of Skull Base Defects with the Nasal Septal Flap SKULL BASE/VOLUME 18, NUMBER 6 2008;385-393